Factors associated with health care access and outcome

This study aims to (1) assess ethnic differences in health care access and health outcome between Asian Americans and whites and between Asian American subgroups, (2) examine effects of cultural factors, and (3) investigate moderating effects of health risk behaviors between cultural characteristics and health care access and outcome. Data were derived from the 2007 California Health Interview Survey. Asian Americans (n = 4,462) and whites (n = 4,470) were included. There were significant ethnic differences in health care access and health perception between Asian Americans and Whites and across Asian American subgroups. Health risk behaviors moderated relationships between cultural factors and health care access and outcome. Findings reveal that ethnicity affects an individual's health care access and health perception, and their health behaviors are an important factor that may improve or worsen outcomes. This study may increase our knowledge base of research and interventions to enhance ethnic minority populations' health care accessibility and perceptions.     

Racial variation in quality of care among Medicare+Choice enrollees

This paper examines racial variation in quality of and access to care experienced by elderly persons enrolled in Medicare+Choice plans. We used eight individual-level Health Plan Employer Data and Information Set (HEDIS) measures to compare whites with blacks, Asians, Hispanics, and Native Americans. Across all measures, black enrollees received lower-quality care. Hispanics and Native Americans were less likely to receive some types of care but were as likely or more likely to receive other types of care. Asians received equal or better care for all measures. It is important that studies of health care quality include all racial subgroups since the black/white patterns may not apply.     

Access to Preventive Services for Adults of Mexican Origin

Immigrants arrive in the U.S. with better than average health, which declines over time. Clinical preventive services can prevent or delay some of that decline, but little research in this area focuses specifically on Mexican immigrants who are the largest contemporary immigrant group. This article finds that recent Mexican immigrants were the least likely to receive preventive care services, even after adjusting for sociodemographic differences in the population. Long-stay Mexican immigrants were more similar to U.S.-born Mexican Americans in preventive service use rates, who in turn had lower rates than U.S.-born non-Latino whites. Monolingual Spanish speaking Mexican immigrants were the least likely to have obtained preventive services. Having no usual source of care is the strongest predictor of the underuse. The persistent gap in preventive services across all subgroups of adults of Mexican origin suggests structural barriers to their preventive care.     

Racial and ethnic differences in access to medical care in managed care plans

OBJECTIVE: To examine the extent to which access differences between racial/ethnic minorities and whites in managed care plans are greater than such differences in other types of health plans. DATA SOURCE: A nationally representative sample of 4,811 African American, 3,379 Hispanic, and 33,737 white nonelderly persons with public or private health insurance. STUDY DESIGN/DATA COLLECTION: A cross-sectional survey of households was conducted during 1996 and 1997. Commonly used measures of access to and utilization of medical care were constructed for individuals: (1) percentage of visits with a usual provider, (2) percentage with a regular provider, (3) visit with a physician in the past year, (4) hospital ER use, (5) last visit was to a specialist. PRINCIPAL FINDINGS: Fewer than 74 percent of Hispanics and African Americans had a regular provider compared to more than 78 percent of white Americans. Hispanics were least likely to have had their last doctor visit with a specialist (22 percent) compared to African Americans (26 percent) and whites (28 percent). Differences between ethnic/racial minorities and whites in managed care plans are similar to differences observed in non-managed care plans. Americans of all racial and ethnic backgrounds in managed care plans with gatekeeping are more likely to have a usual source of care, a regular provider, and lower use of specialists compared to persons in plans without gatekeeping. CONCLUSION: Although greater access to primary care was shown among African Americans and Hispanics in managed care plans, the extent of the disparities between racial/ethnic minorities and whites in managed care is similar to disparities in other types of health plans.     

Influenza and Pneumococcal Vaccination Rates among Vietnamese,Asian, and Non-Hispanic White Americans

Background Vaccination data for Asian Americans are comparable to those for whites, possibly because they are reported in aggregate rather than for subgroups. We compared influenza and pneumococcal vaccination rates among eligible Asian Americans and white Americans, and for Vietnamese Americans as a subgroup, and assessed factors associated with these vaccinations. Methods Cross-sectional study of data collected from three ethnic groups over 4 years by telephone survey. Data were weighted for selection probability and population estimates and analyzed by multivariate logistic regression. Results Vietnamese Americans had a higher rate of influenza vaccination (61%) than Asian Americans (45%) and white Americans (52%), and lower rate of pneumococcal vaccination (41%) than Asian Americans (56%), both lower than white Americans (67%). Conclusion When analyzed as a subgroup, Vietnamese Americans had a higher influenza vaccination rate, but a lower pneumococcal vaccination rate, compared to Asian Americans and white Americans, which may indicate that health behaviors and outcomes can differ widely among Asian subgroups. Analyses of preventive care measures in Asian Americans should focus on subgroups to ensure accuracy and quality of assessments.     

Disparities in health: perspectives of a multi-ethnic, multi-racial America

This 2006 survey of 4,157 randomly selected U.S. adults compared perceptions of health care disparities among fourteen racial and ethnic groups to those of whites. Findings suggest that many ethnic minority groups view their health care situations differently and, often, more negatively than whites. A substantial proportion perceived discrimination in receiving health care, and many felt that they would not receive the best care if they were sick. Most differences remained when socioeconomic characteristics were controlled for. The variety of responses across racial groups demonstrates the importance of examining ethnic subgroups separately rather than combined into a single category.     

Race, rural residence, and control of diabetes and hypertension

PURPOSE: African Americans are at increased risk for diabetes mellitus and hypertension, and rural residents have historically had decreased access to care. It is unclear whether living in a rural area and being African American confers added risks for diagnosis and control of diabetes and hypertension. The purpose of this study was to examine the prevalence of diagnosed diabetes and hypertension, as well as control of both conditions, among rural and urban African Americans and whites. METHODS: We conducted an analysis of the Third National Health and Nutrition Examination Survey (1988-1994). Non-Hispanic African Americans and non-Hispanic white adults 20 years and older were classified according to rural or urban residence (n = 11,755). Investigated outcomes were previously diagnosed diabetes mellitus and hypertension and control of diabetes and hypertension. RESULTS: The prevalence of diagnosed diabetes was 4.5% for urban whites, 6.5% for rural whites, 6.0% for urban African Americans, and 9.5% for rural African Americans. Among patients with diagnosed diabetes, 33% of rural whites, 43% of urban whites, 45% of urban African American, and 61% of rural African Americans had glycosylated hemoglobin (HbA(1c)) levels of 8% or higher (P < .01). Among patients with diagnosed hypertension, 11% of rural whites, 13% of urban whites, 20% of urban African Americans, and 23% of rural African Americans had diastolic blood pressure greater than 90 mmHg (P < .01). In regression models controlling for relevant variables, including body mass index, health status, access to care, education, income, and insurance, compared with rural African Americans, rural and urban whites were significantly more likely to have better glycemic control and diastolic blood pressure control. Urban African Americans also had better diabetes control than rural African Americans. CONCLUSIONS: In this nationally representative sample, rural African Americans are at increased risk for a lack of control of diabetes and hypertension.     

The relationship between lipids/lipoproteins and atherosclerosis in African Americans and whites: the Atherosclerosis Risk in Communities Study

PURPOSE: The relationships between lipids/lipoproteins and atherosclerosis were determined in African Americans and whites to assess the consistency of the relationship between these two groups. Differences could suggest varying biological, environmental, or life-style cofactors influencing development of atherosclerosis. METHODS: In the Atherosclerosis Risk in Communities Study, 2966 African Americans and 9399 whites had determinations of LDL, HDL, HDL2, and HDL3 cholesterol, triglycerides, apolipoprotein A1 and B, and lipoprotein (a). Carotid intimal-medial thickening (IMT) was measured using B-mode ultrasound imaging. RESULTS: The associations, using linear regression, between carotid IMT and LDL cholesterol, HDL cholesterol, and other lipid measurements were significantly weaker in African Americans than whites. Averaging men and women, a 1.034 mmol/L (40 mg/dl) difference in LDL cholesterol was associated with a 0.028 mm IMT difference in whites but a 0.019 difference in African Americans. Similarly, for HDL cholesterol, a 0.44 mmol/L (17 mg/dl) difference is associated wth 0.026 mm difference in carotid IMT in whites and 0.011 mm difference in African Americans. The associations are much weaker in African Americans than whites at the bifurcation and internal carotid, the carotid sites most prone to atherosclerosis. Analysis was done stratifying for risk factors that differ between African Americans and whites, but within most, the relationships remained substantially weaker in African Americans. CONCLUSIONS: We have observed a statistically significant difference in the association between many lipids/lipoproteins and carotid IMT between African Americans and whites. Analysis of many potential cofactors have not provided an explanation for the weaker association. Although possible differences in prior levels of these lipids may provide one explanation for the finding, these results need confirmation in other studies.     

Do managed care plans reduce racial disparities in preventive care?

This study was designed to determine whether managed care plans reduce racial disparities in use of influenza vaccination, mammography, and prostate-specific antigen screening. The study analyzed the use of three types of preventive care in a population-based sample of adults who were 65 years or older and were enrolled in a Medicare managed care (MMC) or fee-for-service (FFS) plan in Allegheny County, Pennsylvania. The study sample included 463 African Americans and 592 whites. Fewer African Americans than whites reported having had an influenza vaccination (64.4% versus 76.5%; p < 0.01) or a prostate-specific antigen test (64% versus 71.2%; p = 0.09) during the previous year. Slightly more African Americans than white women reported having had a mammogram (66.1% versus 63.8%). Logistic regression showed that, regardless of health plan type, African Americans were significantly less likely than whites to have an influenza vaccination (p < 0.05). A MMC plan did not narrow racial differences in preventive care. Reducing disparities may require interventions developed for specific racial/ethnic groups.     

The contribution of insurance coverage and community resources to reducing racial/ethnic disparities in access to care

OBJECTIVE: To examine the extent to which health insurance coverage and available safety net resources reduced racial and ethnic disparities in access to care. DATA SOURCES: Nationally representative sample of 11,692 African American, 10,325 Hispanic, and 74,397 white persons. Nonelderly persons with public or private health insurance and those who were uninsured. STUDY DESIGN: Two cross-sectional surveys of households conducted during 1996-1997 and 1998-1999. DATA COLLECTION: Commonly used measures of access to and utilization of medical care were constructed for individuals. These measures include the following. (1) percent reporting unmet medical needs, (2) percent without a regular health care provider, and (3) no visit with a physician in the past year. FINDINGS: More than 6.5 percent of Hispanic and African Americans reported having unmet medical needs compared to less than 5.6 percent of white Americans. Hispanics were least likely to see the same doctor at their usual source of care (59 percent), compared to African Americans (66 percent) and whites (75 percent). Similarly, Hispanics were less likely than either African Americans or whites to have seen a doctor in the last year (65 percent compared to 76 percent or 79 percent). For Hispanics, more than 80 percent of the difference from whites was due to differences in measured characteristics (e.g., insurance coverage, income, and available safety net services). Differences in measured characteristics between African Americans and whites explained less than 80 percent of the access disparities. CONCLUSION: Lack of health insurance was the single most important factor in white-Hispanic differences for all three measures and for two of the white-African American differences. Income differences were the second most important factor, with one exception. Community characteristics generally were much less important, with one exception. The positive effects of insurance coverage in reducing disparities outweigh benefits of increasing physician charity care or access to emergency rooms.     

Would safety-net expansions offset reduced access resulting from lost insurance coverage? Race/ethnicity differences

This study simulated whether increased community health center (CHC) funding under the Bush administration narrowed racial/ethnic gaps in access to care among low-income people. Expanded CHC funding resulted in small increases in access to care, more so for minorities than for whites. Spanish-speaking Hispanics had the largest improvements in access in the simulation. However, minorities experienced bigger drops in insurance coverage. The net result was no improvements in the access measures for Spanish-speaking Hispanics and slight decreases in access for whites, English-speaking Hispanics, and African Americans. Access gaps either remained the same or worsened slightly for English-speaking Hispanics and African Americans relative to whites.     

How innovative treatment models and data use are improving diabetes care among older African American adults

By 2030, the number of older adults within the United States will have doubled to approximately 71.5 million. Included in this population estimate is the relative growth in the number of older adults of racial and ethnic minority descent. Research has indicated that these individuals, specifically African Americans, have a higher incidence of diabetes than whites, as well as a higher rate of hospitalization compared to whites. This is also true for the older African American. Unfortunately, those with the greatest need for diabetes-related care are least likely to access that care. Moreover, in spite of the indication of need, it is extremely difficult to fully identify strategies that would be optimal for these older minority populations. This paper addresses strategies and techniques to fill gaps in knowledge by detailing efforts, such as the use of health information technologies and multilevel diabetes education teams, to improve the health outcomes of older adult African Americans who have diabetes.     

Prevalence of doctor-diagnosed arthritis and arthritis-attributable effects among Hispanic adults, by Hispanic subgroup--United States, 2002, 2003, 2006, and 2009

Arthritis affects approximately 50 million adults in the United States, making it one of the most prevalent health conditions among U.S. adults and the most common cause of disability. Arthritis is associated with substantial activity limitation, work disability, increased prevalence of obesity, reduced quality of life, and high health-care costs. Among U.S. adults, the prevalence of arthritis and arthritis-attributable effects (e.g., arthritis-attributable activity limitations [AAAL]) varies among racial/ethnic groups; non-Hispanic whites and non-Hispanic blacks have a higher prevalence of doctor- diagnosed arthritis compared with Hispanics, but Hispanics and non-Hispanic blacks have a higher prevalence of arthritis-attributable effects compared with non-Hispanic whites. The prevalence of arthritis and its effects among specific Hispanic subgroups has not been studied in a nationally representative sample of U.S. adults. To determine the annualized prevalence of arthritis and arthritis-attributable effects among Hispanic subgroups, CDC analyzed National Health Interview Survey (NHIS) data for 2002, 2003, 2006, and 2009 combined. This report describes the results of that analysis, which indicated that the age-adjusted prevalence of arthritis ranged from 11.7% among Cubans/Cuban Americans to 21.8% among Puerto Ricans; an estimated 3.1 million Hispanics had arthritis during these years. Among all subgroups of Hispanics with arthritis, at least 20% of persons with arthritis reported an arthritis-attributable effect: AAAL (range: 21.1% among Cubans/Cuban Americans to 48.5% among Puerto Ricans); arthritis-attributable work limitations (AAWL) (range: 32.9% among Central/South Americans to 41.6% among Mexican Americans); and severe joint pain (SJP) (range: 23.7% among Cubans/Cuban Americans to 44.1% among Puerto Ricans). These findings identify Hispanic subgroups with high burdens of arthritis who likely are in need of interventions designed to improve their quality of life.     

Racial/ethnic disparities in adult preventive dental care use

Using the Behavioral Model of Health Services Utilization, this study examines whether adult preventive dental care utilization differs by ethnicity/race. Logistic regression results find that controlling only for predisposing characteristics (gender, age, education, and health status), African Americans, Mexican Americans, and Other race/ethnicity are less likely than whites to utilize dental services. However, the effects are no longer significant when enabling resource variables are included in the model (income level, insurance, census region, and metropolitan statistical area). Interactions between race/ethnicity and insurance status show that privately insured racial/ethnic minority groups do not differ from privately insured whites in their utilization of dental services. Similarly, the preventive dental care utilization of publicly insured African Americans and Other Hispanics does not differ significantly from privately insured whites. However, publicly insured whites, Mexican Americans, and individuals of Other race/ethnicity have significantly lower odds of utilizing dental services relative to whites with private insurance.     

Racial differences in predictors of dental care use

OBJECTIVE: To test five hypotheses that non-Hispanic African Americans (AAs) and non-Hispanic whites (NHWs) differ in responsiveness to new dental symptoms by seeking dental care, and differ in certain predictors of dental care utilization. DATA SOURCES/STUDY SETTING: Florida Dental Care Study, comprising AAs and NHWs 45 years old or older, who had at least one tooth, and who lived in north Florida. STUDY DESIGN: We used a prospective cohort design. The key outcome of interest was whether dental care was received in a given six-month period, after adjusting for the presence of certain time-varying and fixed characteristics. DATA COLLECTION/EXTRACTION METHODS: In-person interviews were conducted at baseline and 24 months after baseline, with six-monthly telephone interviews in between. PRINCIPAL FINDINGS: African Americans were less likely to seek dental care during follow-up, with or without adjusting for key predisposing, enabling, and oral health need characteristics. African Americans were more likely to be problem-oriented dental attenders, to be unable to pay an unexpected $500 dental bill, and to report postbaseline dental problems. However, the effect of certain postbaseline dental signs and symptoms on postbaseline dental care use differed between AAs and NHWs. Although financial circumstance was predictive for both groups, it was more salient for NHWs in separate NHW and AA regressions. Frustration with past dental care, propensity to use a homemade remedy, and dental insurance were significant predictors among AAs, but not among NHWs. The NHWs were much more likely to have sought care for preventive reasons. CONCLUSIONS: Racial differences in responsiveness to new dental symptoms by seeking dental care were evident, as were differences in other predictors of dental care utilization. These differences may contribute to racial disparities in oral health.     

Diabetes and coronary heart disease risk in Mexican Americans.

Mexican Americans have a high prevalence of diabetes relative to non-Hispanic whites, but paradoxically experience a lower prevalence of myocardial infarction and lower cardiovascular mortality (at least in men). To determine whether Mexican Americans might be more resistant to the atherogenic effects of diabetes than non-Hispanic whites, we examined the associations between diabetes and myocardial infarction and selected coronary heart disease (CHD) risk factors in these two ethnic groups. The study population consisted of 5149 Mexican Americans and non-Hispanic whites who were 25 to 64 years old and recruited from the San Antonio Heart Study, a population-based study of cardiovascular risk factors and diabetes conducted between 1979 and 1988. Diabetic men were more than twice as likely to have an electrocardiography (ECG)-documented myocardial infarction than were nondiabetic men, while diabetic women were more than three times as likely to have a myocardial infarction than were nondiabetic women. In both sexes the association between myocardial infarction and diabetes was nearly identical between the two ethnic groups. In both ethnic groups diabetes was also more strongly associated with conventional CHD risk factors (e.g., triglycerides, systolic blood pressure, and high-density-lipoprotein cholesterol) in women than in men. Furthermore, these associations were at least as strong, if not stronger, in Mexican Americans as in non-Hispanic whites. Thus, these data provide no evidence to suggest that Mexican Americans are resistant to the lipid-altering effects of diabetes. We conclude that the protective effect against CHD conferred by Mexican American ethnicity may be obscured in part by the high prevalence of diabetes in this ethnic group.     

The role of attitudes in understanding disparities in adult influenza vaccination

BACKGROUND: Racial/ethnic disparities in influenza vaccine coverage of adults aged 65 years and older persist even after controlling for access, healthcare utilization, and socioeconomic status. Differences in attitudes toward vaccination may help explain these disparities. The purpose of this study was to describe patient characteristics and attitudes toward influenza vaccination among whites and African Americans aged 65 years and older, and to examine their effect on racial disparities in vaccination coverage. METHODS: A cross-sectional telephone survey of Medicare beneficiaries in five U.S. sites, sampled on race/ethnicity and ZIP code. Multivariate analysis controlling for demographics, healthcare utilization, and attitudes toward influenza vaccination was conducted in 2005 to assess racial disparities in vaccine coverage during the 2003-2004 season. RESULTS: The analysis included 1859 white and 1685 African-American respondents; 79% of whites versus 50% of African Americans reported influenza vaccination in the past year (p < 0.00001). Both vaccinated and unvaccinated African Americans were significantly less likely than whites to report positive attitudes toward influenza vaccination. Even among respondents with provider recommendations, respondents with positive attitudes were more likely to be vaccinated than those with negative attitudes. After multivariate adjustment, African Americans had significantly lower odds of influenza vaccination than whites (odds ratio = 0.55, 95% confidence interval = 0.42-0.72). CONCLUSIONS: A significant gap in vaccination coverage between African Americans and whites persisted even after controlling for specific respondent attitudes. Future research should focus on other factors such as vaccine-seeking behavior.     

Urinary phytoestrogen concentrations in the U.S. population (1999-2000)

We report population-based urinary concentrations of phytoestrogens stratified by age, sex, and composite racial/ethnic variables. We measured the isoflavones - genistein, daidzein, equol, and O-desmethylangolensin (O-DMA) - and the lignans - enterolactone and enterodiol - in approximately 2500 urine samples from individuals aged 6 years and older who participated in the National Health and Nutrition Examination Survey (NHANES) in 1999 and 2000. We detected all phytoestrogens in over 70% of the samples analyzed; enterolactone was detected in the highest concentrations, and daidzein was detected with the highest frequency. The geometric means for each phytoestrogen were as follows: genistein, 22.3 microg/g; daidzein, 68.6 microg/g; equol, 7.65 microg/g; O-DMA, 3.95 microg/g; enterolactone, 217 microg/g; and enterodiol, 24.3 microg/g creatinine. The 95th percentiles for each phytoestrogen were as follows: genistein, 380 microg/g; daidzein, 944 microg/g; equol, 50.3 microg/g; O-DMA, 217 microg/g; enterolactone, 2240 microg/g; and enterodiol, 240 microg/g creatinine. Multivariate analyses showed statistically significant differences among many of the demographic subgroups. Adolescents had higher concentrations of genistein and equol than adults. Non-Hispanic whites had higher concentrations of enterodiol and equol than Mexican Americans or non-Hispanic blacks. Non-Hispanic whites also had higher concentrations of enterolactone and O-DMA than Mexican Americans. Mexican Americans had higher concentrations of genistein than non-Hispanic blacks; however, the opposite was found for O-DMA. Determination of phytoestrogen exposure in the US population will help us to better understand phytoestrogen consumption in the US and will assist us in elucidating the potential role of phytoestrogens in protecting against cancer and heart disease.     

Coercive and voluntary referrals: How ethnic minority adults get into mental health treatment

Two hypotheses are typically invoked to examine the referral of adults into mental health care. The first is the clinical behavior hypothesis that suggests the psychiatric problem defines people as dangerous and risky. Accordingly, people with severe mental disorders are more likely to be coercively placed into mental health facilities. The second hypothesis suggests that people with less power are more likely than the powerful to be coercively placed in psychiatric care. We examine the extent to which these hypotheses are supported in a large urban community by investigating referrals into community mental health clinics that serve predominantly poor populations. The data set is unique because it includes four ethnic categories, whites, African Americans, Asian Americans, and Mexican Americans. The findings indicate that the clinical behavior hypothesis is applicable to whites and the stratification hypothesis is consistent with the data for African American, particularly African American men. The referral pattern for Mexican Americans and Asian Americans do not conform to the findings for whites and African Americans. It is likely that other sociocultural factors influence the referrals of these ethnic categories.     

Do Mexican Americans Really Have Low Rates of Cardiovascular Disease?

In this article we challenge the conclusion made from vital statistics that Hispanic Americans have lower all-cause and cardiovascular disease (CVD) mortality than non-Hispanic whites. There is reason to believe that vital statistics underascertain minority, and in particular Hispanic, deaths. Cohort studies minimize many of these limitations. In the San Antonio Heart Study risk factor distributions predicted higher all-cause and CVD mortality among Mexican Americans than among non-Hispanic whites. Follow-up of the cohort confirmed a mortality ratio of 1.38 for all-cause and 1.30 for CVD mortality for Mexican Americans vs non-Hispanic whites. This excess risk was confined to U.S.-born Mexican Americans, since immigrants from Mexico had very low mortality despite low socioeconomic status. We attribute this latter finding to a “healthy migrant effect.”