Long-term care preferences of hospitalized persons with AIDS

Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3) the impact of these views on the resulting discharge dispositions. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care providers. Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care. Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers. Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1; 95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy emerged as important factors to persons with AIDS considering long-term care. Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability, preference, and appropriateness for long-term care. Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood Johnson Clinical Scholars Program during this project. The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Fecal Incontinence in Elderly Koreans

OBJECTIVES: To estimate the prevalence and correlates of fecal incontinence (FI) and its effect on quality of life in ambulatory elderly people in Korea.
DESIGN: Cross-sectional, convenience sample–based survey.
SETTING: Twenty-seven senior citizen centers and two health clinics in two cities of Korea.
PARTICIPANTS: Nine hundred eighty-one relatively healthy and ambulatory community-dwelling people aged 60 and older.
MEASUREMENTS: Data were collected through in-person interviews with a structured questionnaire. Multivariate logistic regression analysis was used to determine independent risk factors for FI.
RESULTS: The prevalence of FI was 15.5%. FI was significantly associated with lower quality of life (Medical Outcomes Study 36-item Short-Form Survey) for physical and mental health. In men, FI was significantly associated with urinary incontinence (odds ratio (OR)=4.89, 95% confidence interval (CI)=2.45–9.77), hemorrhoids (OR=4.66, 95% CI=1.67–12.97), and poor self-perceived health status ( P for trend=.02). In women, FI was associated with urinary incontinence (OR=2.91, 95% CI=1.76–4.81), diabetes mellitus (OR=2.04, 95% CI=1.24–3.37), hemorrhoids (OR=2.99, 95% CI=1.31–6.83), and infrequent dietary fiber intake ( P for trend=.02).
CONCLUSION: FI is prevalent in elderly Koreans and has a profound effect on quality of life. Physicians should closely screen for FI in elderly patients with certain risk factors and evaluate to control these potentially preventable or modifiable factors.     

Electronic Result Viewing and Quality of Care in Small Group Practices

Background There is a paucity of data on the effectiveness of commercially available electronic systems for improving health care in office practices, where the majority of health care is delivered. In particular, the effect of electronic laboratory result viewing on quality of care, including preventive care, chronic disease management, and patient satisfaction, is unclear. Objective To determine whether electronic laboratory result viewing is associated with higher ambulatory care quality. Methods We conducted a cross-sectional study of primary care physicians (PCPs) in the Taconic IPA in New York, all of whom have the opportunity to use a free-standing electronic portal for laboratory result viewing. We analyzed 15 quality measures, reflecting preventive care, chronic disease management, and patient satisfaction, which were collected in 2005. Using generalized estimating equations, we determined associations between portal usage and quality, adjusting for adoption of electronic health records and 10 other physician characteristics, including case mix. Main Results One-third of physicians (54/168, 32%) used the portal at least once over a 6-month period. Use of the portal was associated with higher quality overall (adjusted odds ratio [OR] 1.25; 95% confidence interval [CI] 1.003, 1.57). In stratified analyses, portal usage was associated with higher quality on those performance measures expected to be impacted by result viewing (adjusted OR 1.34; 95% CI 1.00, 1.81; p = 0.05), but not associated with quality for measures not expected to be impacted by result viewing (adjusted OR 1.03; 95% CI 0.72, 1.48; p = 0.85). Conclusion Electronic laboratory result viewing was independently associated with higher ambulatory care quality. Longitudinal studies are needed to confirm this association. An earlier version of this work was presented at the national meeting of the Society of General Internal Medicine in Toronto, Ontario, Canada on April 27, 2007.     

Program

OBJECTIVE: To determine the proportion of primary care patients who are experienced by their physicians as “difficult,” and to assess the association of difficulty with physical and mental disorders, functional impairment, health care utilization, and satisfaction with medical care. DESIGN: Survey. SETTING: Four primary care clinics. PATIENTS: Six-hundred twenty-seven adult patients. MEASUREMENTS: Physician perception of difficulty (Difficult Doctor-Patient Relationship Questionnaire), mental disorders and symptoms (Primary Care Evaluation of Mental Disorders, [PRIME-MD]), functional status (Medical Outcomes Study Short-Form Health Survey [SF-20]), utilization of and satisfaction with medical care by patient self-report. RESULTS: Physicians rated 96 (15%) of their 627 patients as difficult (site range 11–20%). Difficult patients were much more likely than not-difficult patients to have a mental disorder (67% vs 25%, p<.0001). Six psychiatric disorders had particularly strong associations with difficulty: multisomatoform disorder (odds ratio [OR]=12.3, 95% confidence interval [CI]=5.9–25.8), panic disorder (OR=6.9, 95% CI=2.6–18.1), dysthymia (OR=4.2, 95% CI=2.0–8.7), generalized anxiety (OR=3.4, 95% CI=1.7–7.1), major depressive disorder (OR=3.0, 95% CI=1.8–5.3), and probable alcohol abuse or dependence (OR=2.6, 95% CI=1.01–6.7). Compared with not-difficult patients, difficult patients had more functional impairment, higher health care utilization, and lower satisfaction with care, whereas demographic characteristics and physical illnesses were not associated with difficulty. The presence of mental disorders accounted for a substantial proportion of the excess functional impairment and dissatisfaction in difficult patients. CONCLUSIONS: Difficult patients are prevalent in primary care settings and have more psychiatric disorders, functional impairment, health care utilization, and dissatisfaction with care. Future studies are needed to determine whether improved diagnosis and management of mental disorders in difficult patients could diminish their excess disability, health care costs, and dissatisfaction with medical care, as well as the physicians’ experience of difficulty. Presented at the National Meeting of the Society of General Internal Medicine, April 1993. Supported by an unrestricted educational grant from the Roerig and Pratt Pharmaceuticals division of Pfizer Inc.     

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was 0 (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs. This study was supported by a grant from the Emory Medical Care Foundation.     

Clinical correlates of suicidality among individuals with HIV infection and AIDS disease in Mbarara,Uganda

The association between suicidality and HIV/AIDS has been demonstrated for three decades, but little is know about risk factors that can help understand this association and help identify who is most at risk. Few research studies have been conducted in sub-Saharan Africa, a region that accounts for more than 70% of the HIV global burden. This paper describes clinical risk factors for suicidality among individuals with HIV infection and AIDS disease in Mbarara, Uganda. In this study, suicidality includes both suicidal ideation and suicidal attempts. A cross-sectional survey was conducted with 543 HIV-positive individuals aged 15 years and above, recruited from 2 HIV specialised clinics in Mbarara. Using logistic regression analysis, factors significantly associated with suicidality at 95% confidence interval were identified. The rate of suicidality was 10% (n = 54; 95% CI: 5.00–15.00). Risk factors for suicidality were: perception of poor physical health (OR 2.22, 95% CI 1.23–3.99, p = 0.007), physical pain (OR 1.83, 95% CI 1.01–3.30, p = 0.049), reducing work due to illness (OR = 2.22, 95% CI 1.23–3.99, p = 0.004) and recent HIV diagnosis (OR 1.02, 95% CI 1.01–1.03, p = 0.001). These findings suggest that HIV/AIDS in south-western Uganda is associated with a considerable burden of suicidality. HIV is associated with several clinical factors that increase vulnerability to suicidality. There is need for more appropriate interventions targeting these clinical risk factors, systematic suicide risk assessment and management of suicidal ideation and behaviours in HIV care.     

Differences in patient-reported processes and outcomes between men and women with myocardial infarction

OBJECTIVE: Previous research meassuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction. PARTICIPANTS AND SETTING: We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women. MEASUREMENTS: Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status. MAIN RESULTS: In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1.33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0.60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P <.05) and mental health (P<.05), were more likely to report spending time in bed because of ill health (OR 1.80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10.20). CONCLUSIONS: In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men. Dr. Covinsky was supported in part by a clinical investigator award from the National Institute on Aging (1K08AG00714) and is a Paul Beeson Physician Faculty Scholar in Aging Research. Dr. Chren was supported in part by a clinical investigator award from the National Institute of Arthritis, Musculoskeletal and Skin Diseases (K08AR01962). Dr. Rosenthal was a Research Associate, Health Service Research and Development Service, Department of Veterans Affairs, when this study was completed.     

Emergency room visit: a red‐flag indicator for poor diabetes care

Aim To determine the association between emergency room (ER) admission and quality of diabetes care in the community. Methods In a nested case–control study of patients with Type 2 diabetes mellitus (DM) within a large health maintenance organization (HMO) in Israel, 919 patients who were admitted to one of West Jerusalem’s ERs between 1 May and 30 June 2004 were compared with 1952 control subjects not admitted. Data on study covariates were retrieved from the HMO’s computerized database and a subset of the study population was interviewed. Logistic regressions were conducted to estimate the odds ratios of being admitted according to different measures of quality of care, controlling for socio‐demographic variables, co‐morbidities and type of DM treatment. Results The main indices of quality of primary care that were inversely associated with visiting an ER during the study period included performance of a cholesterol test in the year prior to the index date [adjusted odds ratio (OR) 0.23, 95% confidence interval (CI) 0.19–0.29, P < 0.001], performance of glycated haemoglobin test (OR 0.26, 95% CI 0.24–0.29, P < 0.001), visiting an ophthalmologist (OR 0.47, 95% CI 0.32–0.68, P = 0.001), and recommendations to stop smoking (OR 0.10, 95% CI 0.05–0.21, P < 0.001). Conclusions Admission to the ER can be used as an indicator for poor quality of diabetes care. There is an association between ER admission and poor quality of diabetes care.     

Variation in participation in health care settings associated with race and ethnicity

OBJECTIVE: To use the ecology model of health care to contrast participation of black, non-Hispanics (blacks); white, non-Hispanics (whites); and Hispanics of any race (Hispanics) in 5 health care settings and determine whether disparities between those individuals exist among places where they receive care. DESIGN: 1996 Medical Expenditure Panel Survey data were used to estimate the number of black, white, and Hispanic people per 1,000 receiving health care in each setting. SETTING: Physicians’ offices, outpatient clinics, hospital emergency departments, hospitals, and people’s homes. MAIN MEASUREMENT: Number of people per 1,000 per month who had at least one contact in a health care setting. RESULTS: Fewer blacks and Hispanics than whites received care in physicians’ offices (154 vs 155 vs 244 per 1,000 per month, respectively) and outpatient clinics (15 vs 12 vs 24 per 1,000 per month, respectively). There were no significant differences in proportions hospitalized or receiving care in emergency departments. Fewer Hispanics than blacks or whites received home health care services (7 vs 14 vs 14 per 1,000 per month, respectively). After controlling for 7 variables, blacks and Hispanics were less likely than whites to receive care in physicians’ offices (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.60 to 0.69 for blacks and OR, 0.79, 95% CI, 0.73 to 0.85 for Hispanics), outpatient clinics (OR, 0.73, 95% CI, 0.60 to 0.90 for blacks and OR, 0.71, 95% CI, 0.58 to 0.88 for Hispanics), and hospital emergency departments (OR, 0.80, 95% CI, 0.69 to 0.94 for blacks and OR, 0.80, 95% CI, 0.68 to 0.93 for Hispanics) in a typical month. The groups did not differ in the likelihood of receiving care in the hospital or at home. CONCLUSIONS: Fewer blacks and Hispanics than whites received health care in physicians’ offices, outpatient clinics, and emergency departments in contrast to hospitals and home care. Research and programs aimed at reducing disparities in receipt of care specifically in the outpatient setting may have an important role in the quest to reduce racial and ethnic disparities in health.     

Suicidal ideation in primary care

OBJECTIVE: To describe the prevalence and clinical characteristics of primary care patients who report suicidal ideation during the month before their medical visit. DESIGN: Analysis of a self-administered suicidal ideation screening item using sociodemographic data, treatment history, and clinical data from structured interviews. SETTING: Three Rhode Island private family practices, a South Carolina family medicine residency, and a California prepaid internal medicine group practice. PATIEJVTS: Adult primary care patients [N=2,749), 18 to 70 years old, who are able to read and write English, able to complete study forms, and willing to provide informed consent. RESULTS: Sixty-seven (2.44%) of the patients reported suicidal ideation (“feeling suicidal”) during the past month, and most of these patients (58.2%) received no mental health care during that time. The adjusted risk of suicidal ideation was significantly elevated for patients with self-reported fair or poor physical health (odds ratio [OR] 2.5; 95% confidence interval [CI1 1.5, 4.1), fair to poor emotional health (OR 18.0; 95% CI 8.8, 37.0), marital distress (OR 4.4; 95% CI 2.2, 8.8), and recent mental health-related work loss (OR 6.3; 95% CI 3.7, 10.5). In the California sample, patients with major depression (OR 31.2; 95% CI 12.8, 76.1), generalized anxiety disorder (OR 23.4; 95% CI 8.1, 67.1), and drug abuse or dependence (OR 9.6; 95% CI 2.9, 31.6) were at increased risk of suicidal ideation. The “feeling suicidal” item identified 10 of 12 patients who acknowledged a recent plan to kill themselves. CONCLUSIONS: In these primary care patients, suicidal ideation is strongly associated with mental disorder and mental health-related functional impairment, and can be detected with a single self-report “feeling suicidal” item. This research was supported by the Upjohn Company.     

Factors associated with the appropriate use of asthma drugs

BACKGROUND:

When used properly, asthma drugs can reduce asthma-related morbidity and mortality.

OBJECTIVE:

To assess the use of asthma drugs, and to identify factors associated with appropriateness of use among patients 12 to 45 years of age.

METHODS:

Asthmatic patients were interviewed about their asthma drug(s) use and the factors potentially associated with appropriateness of use according to the 2003 Canadian Asthma Consensus Conference guidelines. To determine the factors associated with the appropriate use of asthma drugs, a multivariate logistic regression model was built using a stepwise procedure, and ORs and associated 95% CIs were calculated.

RESULTS:

Of the 349 study participants, 43 (12.3%) reported appropriate use of their asthma drugs. Respondents who were more likely to report appropriate use were patients with sound knowledge of their asthma drugs (OR 2.61 [95% CI 1.29 to 5.29]), those in good, very good or excellent self-perceived health (OR 3.37 [95% CI 1.31 to 8.71]), those who had consulted a specialist during the preceding year (OR 2.28 [95% CI 1.05 to 4.97]) and those who declared themselves short of drugs due to a lack of money (OR 2.78 [95% CI 1.26 to 6.17]).

CONCLUSIONS:

Results of the present study suggested that recommendations in the current guidelines regarding the appropriate use of asthma medications are being poorly implemented. Educational interventions with the aim of improving quality of care and knowledge about asthma drugs should be offered.     

Delivery of primary care to women

OBJECTIVE: Women’s health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women’s health center compared with those at a general medicine clinic. DESIGN: Cross-sectional survey. SETTING: University hospital-affiliated women’s health and general internal medicine clinics. PARTICIPANTS: An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. MEASUREMENTS AND MAIN RESULTS: Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women’s health center. Women’s health center users (n=357) were more likely than general medicine clinic users (n=349) to prefer a female provider (57% vs 32%, p=.0001) and to have sought care at the clinic because of its focus on women’s health (49% vs 17%, p=.0001). After adjusting for age and self-assessed health status, women’s health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2,6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. CONCLUSIONS: These results suggest that, at least in this setting, women’s health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women’s health centers, the quality of general preventive care may be better in general medical clinics. Dr. Phelan was a Robert Wood Johnson Clinical Scholar at the University of Washington. The views, opinions, and conclusions in this article are those of the authors and not necessarily those of the Robert Wood Johnson Foundation.     

Impact of abciximab on mortality and reinfarction in patients with acute ST‐segment elevation myocardial infarction treated with primary stenting

Objectives: To combine data from all randomized trials of abciximab versus placebo or open‐label control in patients with STEMI treated with primary stenting to assess the short‐term and long‐term mortality, reinfarction, and bleeding complications. Background: Clinical trials of adjunctive abciximab therapy in patients with ST‐segment elevation myocardial infarction (STEMI) undergoing primary stenting have produced conflicting results. Methods: Formal searches of electronic databases (Medline, Cochrane) from January 1990 to April 2009 were performed. Five trials randomizing 2,937 patients (1,475 in the abciximab group, 1,462 in the placebo group) were included in the analysis. Results: When compared with placebo, abciximab was not associated with a significant reduction in the odds of 30‐day (OR 0.71, 95% CI: 0.45–1.14, P = 0.16) or long‐term (OR 0.85, 95% CI: 0.48–1.50, P = 0.57) mortality. Similarly, the rate of reinfarction was not statistically different at 30 days (OR 0.59, 95% CI: 0.30–1.17, P = 0.13) or at long‐term follow‐up (OR 0.67; 95% CI: 0.39–1.16, P = 0.16). However, when trials with upstream use of thienopyridines were excluded, abciximab was associated with a significant reduction in the composite of death or reinfarction at 30 days (OR 0.45; 95% CI: 0.26–0.77, P = 0.004) but not at long‐term follow‐up (OR 0.59; 95% CI: 0.27–1.28, P = 0.18). Conclusion: Routine use of abciximab in patients with STEMI treated with primary stenting may reduce short‐term rates of death or reinfarction in patients not administered preprocedural thienopyridine therapy, but does not appear to be beneficial in those who receive preprocedural thienopyridines. © 2009 Wiley‐Liss, Inc.     

Examining health literacy among urban African-American adolescents with asthma

Objective: This exploratory study assessed health literacy among urban African-American high school students to improve understanding of the association between adolescent health literacy and asthma. Methods: We conducted a secondary data analysis of the control group (n = 181) of the Puff City randomized controlled trial (2006–2010), a web-based intervention to promote asthma management among students, grades 9 through 12. A validated self-report 3-item health literacy screening instrument was completed at final online follow-up survey. Logistic regression was used to explore the association between health literacy, demographic characteristics, quality of life, asthma management, and health care utilization. Results: Multivariate analysis revealed that an overall inadequate health literacy score was associated with students who were more likely to be younger (OR 0.61; 95% CI 0.44–0.84), not on Medicaid (OR 0.36; 95% CI 0.17–0.76), have at least one hospitalization (OR 1.29; 95% CI 1.07–1.56); and a lower overall quality of life (OR 0.75; 95% CI 0.59–0.95). Those lacking confidence in filling out medical forms, needing help reading hospital materials, and having difficulty understanding written information were more likely to not have a rescue inhaler (OR 0.49; 95% CI 0.25–0.94), have one or more emergency visits (OR 1.21 95% CI 1.02–1.43), and one or more hospitalizations (OR 1.19; 95% CI 1.01–1.41), respectively. Conclusions: The findings indicate a significant association between inadequate health literary and suboptimal asthma management. It is important to advance understanding of adolescent health literacy, especially those at-risk, as they assume asthma self-management tasks and move toward independent adult self-care.     

Persistent differences in asthma self-efficacy by race,ethnicity, and income in adults with asthma

Abstract

Objective: The objective of this population-based study was to determine if and to what extent there are differences in asthma self-efficacy by race/ethnicity and income, and whether health status, levels of acculturation, and health care factors may explain these differences. Methods: We conducted a secondary data analysis of asthma self-efficacy using the 2009 and 2011–2012 California Health Interview Survey, in adults with asthma (n?=?7874). In order to examine if and how the effect of race/ethnicity and income on asthma self-efficacy may have been altered by health status, acculturation, and health care factors, we used staged multivariable logistic regression models. We conducted mediation analyses to evaluate which of these factors might mediate disparities in self-efficacy by race/ethnicity and income. Results: 69.8% of adults reported having high asthma self-efficacy. Latinos (OR 0.66; 95% CI 0.51–0.86), African-Americans (OR 0.50; 95% CI 0.29–0.83), American Indian/Alaskan Natives (OR 0.55; 95% CI 0.31–0.98) and Asian/Pacific Islanders (OR 0.34; 95% CI 0.23–0.52) were less likely to report high self-efficacy compared to Whites. Individuals with income below the federal poverty level (OR 0.56; 95% CI 0.40–0.78) were less likely to report high self-efficacy compared to higher income individuals. The relationship between income and self-efficacy was no longer significant after further adjustment for health care factors; however, the differences in race and ethnicity persisted. Receiving an asthma management plan mediated the relationship in certain subgroups. Conclusions: Addressing modifiable health care factors may play an important role in reducing disparities in asthma self-efficacy.     

'Closet' quit attempts: prevalence, correlates and association with outcome

Aims To examine the (i) prevalence, (ii) predictors and (iii) cessation outcomes of smokers who engage in undisclosed quit attempts. Design Online survey (n = 524), with balanced recruitment of current smokers (55%) and past‐year quitters (45%). Participants were daily smokers (current or previous) who had at least one quit attempt in the past year. Measurements Respondents were grouped on whether they did versus did not make advanced disclosure to others of their most recent quit attempt. Findings Almost half (n = 234; 45%) reported that their most recent quit attempt was undisclosed to anyone in advance. Those who planned their quit attempt in advance [odds ratio (OR) = 0.10; 95% confidence interval (CI): 0.05–0.23] and those who used behavioral treatment (OR = 0.14; 95% CI: 0.05–0.43) were less likely to make ‘closet quit attempts’, while those who rated their attempt as being serious (OR = 2.52; 95% CI: 1.16–5.46) and those who deemed social support to be unhelpful (OR = 1.91; 95% CI: 1.24–2.95) were more likely to make such attempts. Closet quit attempters were more likely to achieve 30 days of abstinence than were those who made advanced disclosure (67% versus 58%; adjusted OR 1.8; 95% CI: 1.1–2.8), but there were no differences for achieving 6 months of abstinence (52% versus 49%; adjusted OR 1.2; 95% CI: 0.7–2.0). Conclusions Attempting to quit smoking without telling anyone in advance is common, and does not appear to impede success. These findings do not support blanket advice to smokers to tell others about pending quit attempts.     

Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure

PURPOSE: To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure. METHODS: The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure. RESULTS: After adjusting for demographic and clinical characteristics of patients, and the number of eligible measures per patient, we observed no effect of the intervention on care of patients with myocardial infarction (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.81 to 1.17) or heart failure (OR = 1.25; 95% CI: 0.96 to 1.59). However, there was a higher likelihood of conformance with measures for patients with infarction (OR = 1.56; 95% CI: 1.29 to 1.87) or heart failure (OR = 1.71; 95% CI: 1.29 to 2.23) who had also been seen by a cardiologist during the 6-month assessment period. CONCLUSION: Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.     

Characteristics of patients diagnosed with AIDS shortly after first detection of HIV antibodies in Lyon University hospitals from 1985 to 2001

A diagnosis of AIDS shortly after the detection of HIV antibodies suggests a long-lasting course of the disease without care. The factors associated with a short delay between the initial HIV-1-positive test and the first AIDS-defining event were identified in 1901 patients from 1985 to 2001 in Lyon University hospitals. A total of 576 individuals (30.3%) had an interval of /=60 years (OR 4.5; 95% CI 2.5-8.1), compared to those<30 years old; heterosexuality (OR 2.4; 95% CI 1.6-3.4); injection drug use (OR 2.1; 95% CI 1.5-2.7); and other exposures (OR 2.4; 95% CI 1.6-3.4), compared to homosexual exposure; two opportunistic infections at AIDS (OR 1.8; 95% CI 1.4-2.4) compared to one; and Pneumocystis carinii pneumonia as initial AIDS event (OR 2.6; 95% CI 1.8-3.7), compared to Kaposi's sarcoma. These results provide opportunities to refocus local public health interventions to reduce delayed access to care.     

Treatment preferences among depressed primary care patients

OBJECTIVE: To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients. DESIGN: Patient questionnaires and interviews. SETTING: Forty-six primary care clinics in 7 geographic regions of the United States. PARTICIPANTS: One thousand one hundred eighty-seven English-and Spanish-speaking primary care patients with current depressive symptoms. MEASUREMENTS AND MAIN RESULTS: Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P=.001) and had greater knowledge about antidepressant medication (OR, 2.6; 95% CI, 1.6 to 4.4; P≤.001) than those who did not want treatment. A majority (67%, n=660) of those preferring treatment preferred counseling, with African Americans (OR, 2.2; 95% CI, 1.0 to 4.8, P=.04 compared to whites) and those with greater knowledge about counseling (OR, 2.1; 95% CI, 1.6 to 2.7, P≤.001) more likely to choose counseling. Three hundred twelve (47%) of the 660 desiring counseling preferred group over individual counseling. Depression severity was only a predictor of preference among those already in treatment. CONCLUSIONS: Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments. Salary support for Dr. Dwight-Johnson from NIMH grant K 12 MH00990-01-01, Partners in Care study funded by Agency for Health Care Policy and Research grant HS08349-02.     

Risk factors for hepatitis C virus infection among patients receiving health care in a Department of Veterans Affairs hospital

A cross-sectional, seroepidemiological study was conducted to determine the prevalence and risk factors for hepatitis C virus (HCV) infection among veterans receiving health care from the VA. Among 274 evaluated outpatients, anti-HCV was found in 27 (9.9%). The prevalence of anti-HCV was 3.7% among 190 individuals who reported no illicit drug use compared to 24.7% among 81 subjects who had used drugs (P < 0.001). The prevalence of anti-HCV was 4.8% among 208 veterans who had never been incarcerated compared to 27.9% among 61 veterans who had been incarcerated (P < 0.001). A multivariate model found the following factors to be independently associated with anti-HCV: having used illicit drugs [odds ratio (OR) = 3.7, 95% CI 1.3–11.8; P = 0.001), having been incarcerated ( OR = 4.4, 95% CI 1.7–10.9; P = 0.001), and a yearly income less than US $10,000 ( OR = 3.5, 95% CI 1.3–9.4; P = 0.002). Because HCV infection was most strongly associated with illicit drug use, incarceration, and low income, these risk factors should be utilized to develop screening strategies among VA patients.