Preliminary Report of a Palliative Care and Case Management Project in an Emergency Department for Chronically Ill Elderly Patients

The Palliative Care Service at Montefiore Medical Center (MMC) established a pilot project in the emergency department (ED) to identify chronically ill older adults in need of palliative care, homecare, and hospice services and to link such patients with these services. Two advance practice nurses conducted consultations on elderly patients who were found to have one or more “palliative care triggers” on initial screening. A standardized medical record abstraction form was developed. Service utilization and survival were evaluated using the Clinical Information Systems of MMC. Activity of daily living items were developed from the Outcome and Assessment Information Set and the Palliative Care Performance Scale (PPS). Risk factors for hospitalization and use of the ED were taken from the SIGNET model risk screening tool. Physical and emotional symptoms were evaluated using the 28-item Memorial Symptom Assessment Scale short form. Preliminary outcomes and characteristics are presented for 291 patients who completed the intake needs assessment questionnaire. Almost one third (30.9%) of the study cohort died during the project period. Most of the deaths occurred beyond the medical center (7.7% died in the medical center and 23.3% outside the medical center). Thirty percent of patients who died were enrolled on a hospice. Survival time was predicted by the presence of dyspnea, clinician prediction of death on the current hospitalization, psychosocial distress, and PPS scores. Chronically ill patients visiting an urban community ED had complex medical and psychosocial problems with limited support systems and homecare services. Significant proportions of such patients can be expected to have limited likelihood of survival. The presence of palliative homecare and hospice outreach services in the ED in urban community hospitals may provide an effective strategy for linkage of elderly patients at the end of life with otherwise underutilized services. O’ Mahony, Simpson, Huvane, McHugh, Hutcheson, Karakas, and Higgins are with the Palliative Care Service, Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Blank and Selwyn are with the Department of Family and Social Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Persaud is with the Memorial Sloan Kettering Cancer Center, New York, NY, USA; McAllen and Davitt are with the Emergency Department, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA.     

Teenage pregnancy in an urban hospital setting

Recent research suggests that adverse consequences of teenage pregnancy are largely a function of social background factors and adequacy of prenatal care. This study examines the situation of young mothers with new babies in a low income, urban environment. The study explores the relationship between age and ethnicity and various life circumstance and life style differences which might effect long term developmental outcome. 475 Hispanic and black mothers were interviewed using a structured questionnaire. The majority are poorly educated, single parents. Educational attainment is higher for blacks than for Hispanics and for older mothers than for younger. Older mothers are more likely to be living with the father, to be married, and to have received adequate prenatal care. Hispanic parents are more likely than Blacks to be planning to live together. Hispanic mothers are more likely than blacks to be planning to be the primary caretaker for their babies. Adequacy of prenatal care is related to both prematurity and low birth weight. The implications of these findings are discussed in relation to pregnancy prevention and parenting education programs.J. Kent Davis, Ph.D. is Chief of Psychological Services and Assistant Professor in the Department of Pediatrics at the New York Medical College, Valhalla, New York. Raymond Fink, Ph.D. is Professor in the Department of Community Medicine at the New York Medical College, Valhalla, New York. Benamana Rajegowda, M.D. is Associate Professor in the Department of Pediatrics at the New York Medical College and Director of the Neonatal Intensive Care Unit at the Lincoln Medical and Mental Health Center, Bronx, New York. Arun Yesupria, M.D. is Chairman of STAT Clinical Laboratories in India. Rasila Lala, M.D. is Assistant Professor in the Department of Pediatrics at the New York Medical College and an attending Neonatologist at Lincoln Medical and Mental Health Center, Bronx, New York.     

Suicide Tourism in Manhattan,New York City, 1990–2004

Suicide accounts for over 30,000 deaths per year in the United States and is associated with psychiatric illness and substance abuse. Research suggests a strong relationship between method of suicide and the lethal means that are readily available in one’s community of residence. However, certain individuals may also seek the opportunity for suicide outside their proximal environment, often in well-known places. Whereas prevention efforts have been aimed at certain repeatedly used sites for suicide (i.e., Golden Gate Bridge), little research has studied “suicide tourism,” the phenomenon of out of town accompanied by suicide. We collected data on all suicide deaths in New York City (NYC) between 1990 and 2004 from the Office of the Chief Medical Examiner of NYC. We examined trends and correlates of out-of-town residents who committed suicide in NYC. Manhattan accounted for 274 of the 407 nonresident suicides in NYC, which represented over 10% of all suicides committed in Manhattan. The most common methods of suicide for the Manhattan nonresidents were long fall, hanging, overdose, drowning, and firearms; the most common locations included hotels and commercial buildings, followed by outside locations such as bridges, parks, and streets. Nonresident victims tended to be younger, more often white and Asian and less often black and Hispanic than their residential counterparts. An analysis of nonresident suicides in Manhattan revealed that it is a location where individuals travel and take their lives, often by similar means and in similar locations. A comparison with residential suicide implied that a different type of individual is at risk for nonresidential suicide, and further research and prevention efforts should be considered. Gross and Tardiff are with the Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA; Gross is with the Subprogram in Clinical Psychology, The Graduate Center, City University of New York, New York, NY, USA; Markham Piper, Bucciarelli, Vlahov and Galea are with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Galea is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.     

Predictors of Partner Notification for C. trachomatis and N. gonorrhoeae: An Examination of Social Cognitive and Psychological Factors

Efforts to control chlamydial and gonococcal infections include notifying eligible sexual partners of possible infection, primarily by asking the diagnosed patient to notify their partners. This approach, known as patient referral, is widely used but poorly understood. The current study examined psychosocial and cognitive factors associated with patient referral among an urban, minority sample of 168 participants recently diagnosed with Chlamydia trachomatis or Neisseria gonorrhoeae. At a follow-up interview 1-month from diagnosis, participants were more likely to have notified all eligible partners if they had greater intention to notify at baseline (OR = 3.72; 95% CI = 1.34, 10.30) and if they had only one partner at baseline (OR = 4.08; 95% CI = 1.61, 10.31). There were also gender differences as well as differences based on type of partner (i.e., regular, casual, one-time). The implications of these findings for the design of programs to promote patient referral for sexually transmitted infections are discussed. Schwartz, Malka, Augenbraun, McCormack, and Wilson are with the State University of New York, Downstate Medical Center, Brooklyn, NY, USA; Rubin is with the New York City Department of Health, Bureau of STD Control, New York, NY, USA; Rubin, Hogben, and Liddon are with the Centers for Disease Control and Prevention, Atlanta, GA, USA; Schwartz is with the Department of Preventive Medicine and Community Health, SUNY Downstate Medical Center, Box 1240, 450 Clarkson Avenue, Brooklyn, NY 11203, USA.     

Challenges and Facilitating Factors in Sustaining Community-Based Participatory Research Partnerships: Lessons Learned from the Detroit, New York City and Seattle Urban Research Centers

In order to address the social, physical and economic determinants of urban health, researchers, public health practitioners, and community members have turned to more comprehensive and participatory approaches to research and interventions. One such approach, community-based participatory research (CBPR) in public health, has received considerable attention over the past decade, and numerous publications have described theoretical underpinnings, values, principles and practice. Issues related to the long-term sustainability of partnerships and activities have received limited attention. The purpose of this article is to examine the experiences and lessons learned from three Urban Research Centers (URCs) in Detroit, New York City, and Seattle, which were initially established in 1995 with core support from the Centers for Disease Control and Prevention (CDC). The experience of these Centers after core funding ceased in 2003 provides a case study to identify the challenges and facilitating factors for sustaining partnerships. We examine three broad dimensions of CBPR partnerships that we consider important for sustainability: (1) sustaining relationships and commitments among the partners involved; (2) sustaining the knowledge, capacity and values generated from the partnership; and (3) sustaining funding, staff, programs, policy changes and the partnership itself. We discuss the challenges faced by the URCs in sustaining these dimensions and the strategies used to overcome these challenges. Based on these experiences, we offer recommendations for: strategies that partnerships may find useful in sustaining their CBPR efforts; ways in which a Center mechanism can be useful for promoting sustainability; and considerations for funders of CBPR to increase sustainability. Israel, Lichtenstein, and McGranaghan are with the University of Michigan, School of Public Health, Ann Arbor, MI, USA; Krieger and Ciske are with the Epidemiology, Planning and Evaluation Unit, Public Health—Seattle & King Country, Seattle, WA, USA; Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Foley is with the Department of Community and Preventive Medicine, Mt. Sinai Medical School, New York, NY, USA; Fortin is City Research Scientist, New York City Department of Health, New York, NY, USA; Guzman is with the Community Health and Social Services, Inc., Detroit, MI, USA; Palerno is with the Center for Multicultural and Community Affairs, Mount Sinai School of Medicine, New York, NY, USA; Tang is with the Aging and Adult Services Company, Asian Counseling and Referral Services, Seattle, WA, USA. The first three authors are the Principal Investigators of the three Urban Research Centers. The other coauthors from the three Centers are listed in alphabetical order. See the acknowledgements at the end for a list of all of the partner organizations involved.     

The Urban Environment and Sexual Risk Behavior among Men who have Sex with Men

Increasingly, studies show that characteristics of the urban environment influence a wide variety of health behaviors and disease outcomes, yet few studies have focused on the sexual risk behaviors of men who have sex with men (MSM). This focus is important as many gay men reside in or move to urban areas, and sexual risk behaviors and associated outcomes have increased among some urban MSM in recent years. As interventions aimed at changing individual-level risk behaviors have shown mainly short-term effects, consideration of broader environmental influences is needed. Previous efforts to assess the influence of environmental characteristics on sexual behaviors and related health outcomes among the general population have generally applied three theories as explanatory models: physical disorder, social disorganization and social norms theories. In these models, the intervening mechanisms specified to link environmental characteristics to individual-level outcomes include stress, collective efficacy, and social influence processes, respectively. Whether these models can be empirically supported in generating inferences about the sexual behavior of urban MSM is underdeveloped. Conceptualizing sexual risk among MSM to include social and physical environmental characteristics provides a basis for generating novel and holistic disease prevention and health promotion interventions. Frye, Latka, Putnam, Galea, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA; Koblin is with the New York Blood Center, New York, NY, USA; Halkitis is with the Department of Applied Psychology, New York University, New York, NY, USA; Vlahov is with the Department of Epidemiology, Columbia University, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA.     

Men, Multiple Sexual Partners, and Young Adults’ Sexual Relationships: Understanding the Role of Gender in the Study of Risk

Heterosexual transmission of HIV and other sexually transmitted infections has become a primary health concern worldwide. Gender roles for heterosexual interactions appear to sanction men’s sexual risk-taking, especially the pursuit of multiple sexual partners. Using measures developed in this study, the current study assessed the associations between men’s and women’s relationship attitudes and experiences and their sexual risk encounters. Participants were 104 men and 103 women (18–24 years) from a large, urban college located in a high HIV risk neighborhood of New York City. All completed a survey assessing HIV risk and the battery of relationship measures assessing traditional sexual roles, sexual conflicts, significance of sex, relationship investment, need for relationship, and unwanted sex. For men, greater sexual conflict in their primary relationships was associated with more sexual partners and fewer unprotected vaginal intercourse encounters with a primary partner and across sex partners overall. In addition, men’s endorsement of more traditional sexual roles and lower relationship investment were associated with higher numbers of sexual partners. Among women, compliance with men to engage in unwanted sex was associated with higher levels of participation in unprotected sex. For both men and women, greater significance given to sex in a relationship was associated with fewer extradyadic partners. This study demonstrates the utility of measures of relationship attitudes and experiences to characterize sexual risk, especially among men. Findings are discussed in terms of implications for prevention program targeting young urban adults.O’Sullivan is with the Department of Family & Social Medicine, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer 100, Bronx, NY 10461, USA; O’Sullivan, Hoffman, and Dolezal are with the HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, NY, USA; Hoffman is with the Department of Epidemiology, Joseph L. Mailman School of Public Health, Columbia University, New York, NY, USA; Harrison is with the Department of Medicine, Division of Infectious Diseases and Population Studies and Training Center, Brown University, Providence, RI 02912, USA.     

A multiple entry system for psychiatric clinics

The authors studied the characteristics of 100 patients who applied for psychiatric treatment at the clinic of the Bronx Municipal Hospital Center and did not keep their initial appointment. This group was compared with a matched group of 100 patients who kept their initial appointments. Eighty-two of the “no show” group responded to a mail and telephone inquiry. The characteristics of particular subgroups were identified in relation to the percentage of appointments kept. Among the most significant factors were the male-female distribution, and the source of referral. The hypothesis is advanced that a single entry system for admission to psychiatric clinics, using an appointment or “walk-in” approach, does not promote easy entrance for many in need of treatment. Certain systems of entry into a clinic are suitable for particular subgroups, but not for others. The findings are discussed in relation to other studies of pre-intake clinic dropout. From the Department of Psychiatry of the Albert Einstein College of Medicine, Bronx, N.Y., where Dr. Stein is Director, Psychiatric Out-Patient Services, Bronx Municipal Hospital Center and Assistant Clinical Professor; Dr. Karasu is Associate Director, Department of Psychiatry, Bronx Municipal Hospital Center and Assistant Professor, and Mr. Charles is Research Associate, Bronx Municipal Hospital Center. [Dr. Stein, Psychiatric Out-Patient Clinic, 1165 Morris Park Ave., Bronx, N. Y. 10467]     

Co-located Substance Use Treatment and HIV Prevention and Primary Care Services,New York State, 1990–2002: A Model for Effective Service Delivery to a High-Risk Population

The New York State Department of Health (NYSDOH) AIDS Institute (AI) began an initiative in 1990 in collaboration with the Office of Alcoholism and Substance Abuse Services (OASAS) to colocate HIV prevention and clinical services at drug treatment clinics. In 1990, the initiative began funding drug treatment programs to provide HIV counseling, testing, and prevention services. HIV primary care was added the following year. Program implementation and development are described. An analysis is included of HIV counseling and testing data for the period 1990–2002 and quality of care data for five standardized quality measures with comparisons to data from other clinical settings. In the first 13 years of the initiative 168,340 HIV-antibody tests were conducted including 52,562 tests of injection drug users (IDUs) identifying 14,612 HIV-infected persons; the seroprevalence was 8.68%. By the end of 2000, the HIV primary care caseload peaked at 3,815 patients. Quality of primary medical care services among participating drug treatment programs has consistently matched or exceeded that provided in more conventional health care settings such as the hospitals and community health centers that were used as a basis for comparison. Colocating HIV primary care within substance use treatment is an effective strategy for providing accessible high-quality HIV prevention and primary care services. Rothman is with the Bureau of HIV Ambulatory Care, AIDS Institute, New York State Department of Health, Albany, New York, USA; Rudnick and Slifer are with the Substance Abuse Unit, AIDS Institute, New York, NY, USA; Agins is with the Office of the Medical Director, AIDS Institute, New York, NY, USA; Heiner is with the Karl Heiner Statistical Consulting, Ltd., Schenectady, New York, USA; Birkhead is with the AIDS Institute, Albany, New York, USA.     

Aging and HIV Infection

With the advent of highly active antiretroviral therapy (HAART) in mid-1995, the prognosis for HIV-infected individuals has brightened dramatically. However, the conjunction of potent antiviral therapy and longer life expectancy may engender a variety of health risks that, heretofore, HIV specialists have not had to confront. The long-term effects of HIV infection itself and exposure to antiretroviral agents is unknown. Several aspects of aging, including psychiatric disease, neurocognitive impairment, and metabolic and hormonal disorders, may be influenced by chronic exposure to HIV and/or HIV therapeutics. In this paper, we discuss the health issues confronting HIV-infected older adults and areas for future research. Dr. Klein and Dr. Schoenbaun are with the Division of Infectious Diseases, Department of Medicine and The AIDS Research Program, Department of Epidemiology and Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Anastos is with the Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY; Dr. Minkoff is with the Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, NY; Dr. Sacks is with the Department of Community and Preventive Medicine, Mount Sinai School of Medicine, New York, NY.     

Integrating HIV Prevention Activities into the HIV Medical Care Setting: A Report from the NYC HIV Centers Consortium

With the maturing of the HIV epidemic and availability of potent antiretroviral therapies in the US, priorities for HIV prevention have shifted from general population approaches to case finding, treatment, risk reduction and relapse prevention activities among those at greatest risk for acquiring or transmitting HIV infection. The challenges of this approach include ensuring access and adherence to HIV care and treatment and appropriate prevention activities to ensure adequate and sustained sexual and drug use risk reduction across diverse populations. Experience with approaches to address these issues, particularly in the context of primary care, has been limited. An agenda for future research and practice includes continued development and evaluation of interventions that can address this next generation of health care issues. Vlahov is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, USA; Crystal is with the AIDS Research Group, Rutgers the State University of New Jersey, USA; Absalon is with the Center for Infectious Disease Epidemiologic Research, Mailman School of Public Health, Columbia University, USA; Klein and Agins are with the New York State Department of Health, AIDS Institute, USA; Remien is with the HIV Center for Clinical and Behavioral Studies, Columbia University and the NY State Psychiatric Institute, USA. An erratum to this article can be found at     

Sampling and Recruitment in Multilevel Studies among Marginalized Urban Populations: The IMPACT Studies

Illicit drug use in urban settings is a major public health problem. A range of individual level factors are known to influence drug use and its consequences, and a number of recent studies have suggested that the neighborhood in which an individual lives may also play a role. However, studies seeking to identify neighborhood-level determinants of drug use, particularly among marginalized urban populations, need to overcome significant challenges, particularly in the area of sampling and recruitment. One key issue is defining functional neighborhoods that are relevant to local residents. Another arises from the need to sample a representative or even a diverse population when studying marginalized groups such as illicit drug users. These are common problems that raise particular challenges when both need to be addressed in the same study. For example, many sampling approaches for neighborhood-level studies have included some form of random sample of households, but this may systematically overlook marginalized populations. On the other hand, the sampling approaches commonly used in studies of hidden populations such as chain referral, snow ball, and more recently, respondent-driven sampling, typically expand beyond a geographic “neighborhood.” We describe the organization and rationale for the IMPACT Studies in New York City as a case illustration on how such issues may be addressed. Ompad, Galea, Fuller, Weiss, Beard, Chan, Edwards, and Vlahov are with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Marshall is with the RAND Corporation, Santa Monica, CA, USA; Fuller and Vlahov are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.     

Resistance to HIV Infection

The biological correlates of an effective immune response that could contain or prevent HIV infection remain elusive despite substantial scientific accomplishments in understanding the interactions among the virus, the individual and the community. The observation that some individuals appear to possess resistance to HIV infection or its consequences has generated a host of epidemiologic investigations to identify biological or behavioral characteristics of these individuals. These data might hold the keys to developing appropriate strategies for mimicking the effective responses of those who appear immune. In this paper we review genetic mechanisms including the role of chemokines and their receptors, cytokines, host genetic immune response to HIV infection, local immune response correlating with behavioral variables, co-infection and immune based mechanisms that have been elucidated so far. We offer suggestions for how to use these observations as platforms for future research to further understand natural resistance to HIV infection through cohort studies, population genotype sampling, mathematical modeling of virus–host interactions and behavioral analyses. Marmor, Hertzmark and Thomas are with the Department of Environmental Medicine, New York University School of Medicine, 650 First Avenue, Room 560, New York, NY 10016, USA; Marmor is with the Department of Medicine, New York University School of Medicine, New York, NY, USA; Marmor, Hertzmark, Thomas, and Halkitis are with the The Center for AIDS Research, New York University School of Medicine, New York, NY, USA. Halkitis is with the Department of Applied Psychology, New York University Steinhardt School of Education, New York, NY, USA; Vogler is with the Division of International Medicine and Infectious Diseases, Weill Cornell College of Medicine, New York, NY, USA.     

Unreimbursed expenses for medical care among urban elderly people

Out-of-pocket medical expenditures were examined among a sample of 400 low-to-moderate income Medicare recipients living in the Bronx for a twelve month period in 1986–87. Using three different measures of magnitude, the most significant expenses were for Medicare and private insurance premiums, medications, and dental care. The mean percent of per capita income spent out-of-pocket for medical care (including health care premiums) was 11.0%. Elderly people who spend over 12% of their own income on medical care include those in the poorest health, those with annual incomes under $15,000, people living with spouses or others, and those using a private physician as a primary source of medical care.Cynthia Thomas, Ph.D. is Senior Research Associate, Howard R. Kelman, Ph.D. is Director, Division of Health Services Organization & Policy, Department of Epidemiology and Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York 10467. Portions of these data were presented at the American Public Health Association Annual Meeting, New Orleans, Louisiana, October 18–22, 1987. Supported by grants from the United Hospital Fund of New York and the National Institute on Aging (PO1 AGO3424 and RO1AGO8125)The authors would like to thank Lourdes Foley and Irene Young for their patient and careful preparation of the data for analysis.     

Hospital reported complications of laparoscopic cholecystectomy among Medicare and Medicaid patients

The purpose of this study was to initiate a hospital-based case review of all laparoscopic cholecystectomies performed on Medicare and Medicaid patients in New York State in 1991 where there were one or more complications. Another purpose was to facilitate efforts by hospitals to monitor the performance of laparoscopic cholecystectomy through an educational process of data-sharing.There were 2,940 Medicare and 1,108 Medicaid cholecystectomies in New York State in 1991. Of these, 351 (11.9%) Medicare and 107 (9.7%) Medicaid patients were reported as having complications. The complication rate for Medicare patients was slightly lower than that observed (15.8%) in an epidemiologic study of Medicare patients in New York State who underwent laparoscopic cholecystectomy during the period January 1, 1990–June 30, 1991.Both of these observed rates for Medicare patients are higher than the mean 6.0% complication rate reported for open cholecystectomy in the literature. These increased rates may in part be due to age related risk factors present among Medicare patients. The absence of age related risk factors may also largely account for the lower laparoscopic cholecystectomy complication rate (9.7%) observed among Medicaid patients.The complication rate of 9.7% for Medicaid patients is similar to rates reported in other recent studies. The 11.9% complication rate for Medicare patients is higher than that reported in other recent studies. However, careful patient selection, the absence of age related risk factors, and greater surgical experience may account for the lower complication rates reported in some published series.Overall, the coding of complications was found to be accurate. The coding of laparoscopic cholecystectomy was found to be slightly flawed.Few of the adverse events leading to complications were deemed preventable by the hospitals. Surgeons often dealt with intraoperative problems by converting to a conventional open procedure.Hospitals should continue to monitor their experience with laparoscopic cholecystectomies over time, and should provide educational feedback to their medical staffs regarding these findings.Raphael P. Nenner, M.D. is Vice President for Medical Affairs for the Island Peer Review Organization (IPRO), 1979 Marcus Ave, Lake Success, NY 11042; Pascal James Imperato, M.D. is Medical Director for Research, Development, and Epidemiology (IPRO) and Professor and Chairman, Department of Preventive Medicine and Community Health, State University of New York (SUNY), Health Science Center at Brooklyn, 450 Clarkson Ave, Brooklyn, NY 11203; Theodore O. Will, M.P.A., is Executive Vice President (IPRO); Harriet Starr, M.A. is Vice-President for Management Information Systems (IPRO); Harry S. Soroff, M.D., (IPRO) and Professor, Department of Surgery, State University of New York, Health Sciences Center at Stony Brook, Stony Brook, NY 11794- 3399.We wish to acknowledge the assistance of Gary B. Beringer, Dr. P.H., Director, Department of Data Analysis, Island Peer Review Organization (IPRO); John Zetsche, M.A., Research Analyst, and H. Peter Lee, S.B., Research Analyst, IPRO.     

Combining Clinical and Population-Level Data to Understand the Health of Neighborhoods

From February through December 2012, we examined responses to health behavior questions integrated into the electronic medical record of primary care centers in the Bronx, New York in the context of New York City Community Health Survey data. We saw a higher proportion of unhealthy behaviors among patients than among the neighborhood population. Analyzing clinical data in the neighborhood context can better target at-risk populations.Primary clinical care and population health have complementary goals of improving the health of patients and neighborhoods, respectively.1,2 However, clinical care centers and public health agencies rarely operate in concert to increase wellness at both the patient and population levels. The systems for collecting and analyzing patient- and population-level data are often not coordinated or connected,3,4 making the examination of changes in patient outcomes difficult to interpret within the context of larger population trends. Using a set of common metrics allows the assessment of intervention effectiveness in both the clinical and neighborhood settings.As part of a common interest and shared vision to improve clinical outcomes for patients as well as the health of the broader community, Montefiore Medical Center (MMC), the Bronx District Public Health Office of the New York City Department of Health and Mental Hygiene (DOHMH), and the Bronx Community Health Network, Inc, established a partnership in 2010—formally known as Bronx CATCH (Collective Action to Transform Community Health) to pursue a geographic approach to promoting health in specified neighborhoods in the Bronx, New York. This collaboration of hospital, department of health, and community partners in the Bronx was designed to integrate a set of population health metrics into MMC’s clinical electronic medical record. We created the data infrastructure whereby comparable metrics at the clinic and population levels are collected. We have presented the results of the first year of behavioral health data collected through the electronic medical record for patients receiving routine primary care at 3 neighborhood health centers in 3 Bronx communities.     

The Relative Effect of Household and Workplace Smoking Restriction on Health Status Among Chinese Americans Living in New York City

Households and workplaces are the predominant location for exposure to secondhand smoke. The purpose of this study is to examine the association between health status and smoking restrictions at home and work and to compare the relative effect of household and workplace smoking restrictions on health status. This study uses data from a cross sectional representative probability sample of 2,537 Chinese American adults aged 18–74 living in New York City. The analysis was limited to 1,472 respondents who work indoors for wages. Forty-three percent of respondents reported a total smoking ban at home and the workplace, 20% at work only, 22% home only, and 15% reported no smoking restriction at home or work. Smokers who live under a total household smoking ban only or both a total household and total workplace ban were respectively 1.90 and 2.61 times more likely to report better health status compared with those who reported no smoking ban at work or home. Before the NYC Clean Indoor Air Act second-hand smoke (SHS) exposure among this immigrant Chinese population at home and work was high. This study finds that household smoking restrictions are more strongly associated with better health status than workplace smoking restrictions. However, better health status was most strongly associated with both a ban at work and home. Public health efforts should include a focus on promoting total household smoking bans to reduce the well-documented health risks of SHS exposure. Shelley and Hung are with the Department of Sociomedical Sciences, Columbia University Mailman School of Public Health, New York, NY, USA; Yerneni and Fahs are with the Brookdale Center on Aging, Hunter College, City University of New York, New York, NY, USA. Fahs and Das are with the Economics Program Graduate Center, City University of New York, New York, USA. An erratum to this article can be found at     

The emergence of depressive symptoms in late life: The importance of declining health and increasing disability

Despite considerable progress in the epidemiology of late life depressive disorders, the determinants and course of late life depressive symptoms remain unclear. The apparent reciprocal relationship between depression and disability, a consistent finding in cross-sectional studies further confounds efforts to estimate the importance of depressive symptoms in the elderly. In a longitudinal study of 1457 aged community residents who completed the Center for Epidemiologic Studies Depression scale at baseline and 24 months later, a significant level of depressive symptoms emerged in 163 respondents (11%), while 1080 (74%) remained symptom free. Unlike other studies, we found that the number of medical conditions, social support, life events, and demographic characteristics contributed little to distinguish those with emerging symptoms from those who remained symptom free. However, increasing disability and declining health preceded the emergence of depressive symptoms and accounted for seventy percent of the variance explained by discriminant analysis. These findings have etiologic implications for both the course and determinants of depression in late life.Gary J. Kennedy, M.D. is Director, Division of Geriatric Psychiatry, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx Psychiatric Center; Howard R. Kelman, Ph.D. is Director, Division of Health Services Organization and Policy, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Cynthia Thomas, Ph.D. is Senior Research Associate, Division of Health Services Organization and Policy, Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Montefiore Medical Center.Supported in part by grants P01 AG03424 and R01 AG08125 from the National Institute on Aging     

Colonoscopy demand and capacity in New Hampshire

BACKGROUND: Screening for colorectal cancer has been clearly shown to decrease the incidence and mortality from this disease. Accurate information about the demand and capacity for screening, particularly with colonoscopy, is critical in planning screening strategies. National assessments have recently begun; estimates of smaller geographic regions should improve the accuracy of national estimates, as well as inform strategies for individual states. This study evaluates the demand and capacity for colonoscopy in the state of New Hampshire. METHODS: All endoscopy sites in the state of New Hampshire were contacted to determine their number of endoscopists, monthly colonoscopies, and estimates of the percentage of colonoscopy done for screening. Barriers to increasing current capacity were also assessed. The capacity estimates were compared to demand estimates based on population census figures. Data were collected in 2003 to 2004 and analyzed in 2005 to 2006. RESULTS: One hundred fourteen endoscopists at 36 centers performed 49,352 colonoscopies in 2002, an average of 39 to 43 total monthly colonoscopies per endoscopist. Approximately 60% were estimated to have been done for screening. Estimated demand was approximately twice the available capacity for screening and surveillance. The impact of factors such as compliance, percent screening, and population growth were assessed to inform future screening strategies. CONCLUSIONS: In 2002, demand for screening colonoscopy in New Hampshire for patients aged more than 50 years was approximately twice the available capacity. However, if the assessed screening capacity of 2002 were to increase by 20%, combined with a target of 60% population compliance with screening as an initial goal, the demand for colonoscopy in New Hampshire would be met.     

Symptoms of Posttraumatic Stress Disorder in a New Orleans Workforce Following Hurricane Katrina

On August 29, 2005, Hurricane Katrina made landfall resulting in catastrophic damage and flooding to New Orleans, LA, and the Gulf Coast, which may have had significant mental health effects on the population. To determine rates and predictors of symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) in New Orleans residents following Hurricane Katrina, we conducted a web-based survey 6 months after Hurricane Katrina made landfall. Participants included 1,542 employees from the largest employer in New Orleans. The prevalence of PTSD symptoms was 19.2%. Predictors of PTSD symptoms in a multivariate-adjusted regression model included female sex, non-black race, knowing someone who died in the storm, not having property insurance, having had a longer evacuation, a much longer work commute compared to before Hurricane Katrina, and currently living in a newly purchased or rented house or in a temporary trailer. Despite universal health coverage and the benefits of an employee assistance program for all employees, only 28.5% of those with PTSD symptoms had talked to a health professional about the events of Hurricane Katrina or issues encountered since the storm. A significant burden of PTSD symptoms was present 6 months following Hurricane Katrina among a large group of adults who had returned to work in New Orleans. Given their key role in the economic redevelopment of the region, there is a tremendous need to identify those in the workforce with symptoms consistent with PTSD and to enhance treatment options. The strong relationship between displacement from ones’ pre-Katrina residence and symptoms of PTSD suggests a need to focus resource utilization and interventions on individuals living in temporary housing. DeSalvo, Tynes, and Muntner are with the Section of General Internal Medicine and Geriatrics, Tulane University School of Medicine, New Orleans, LA, USA; DeSalvo, Hyre, Menke, and Muntner are with the Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA; Ompad is with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Tynes is with the Department of Psychiatry, Tulane University School of Medicine, New Orleans, LA, USA; Tynes is with the Jefferson Parish Human Services Authority, Metairie, LA, USA.