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.     

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.     

Evaluation of an Intervention to Increase Screening Colonoscopy in an Urban Public Hospital Setting

Only 50% of New Yorkers aged 50 and over reported ever being screened for colorectal cancer by any modality according to a recent household survey. The objective of this investigation was to assess the impact of a hospital-based intervention aimed at eliminating health care system barriers to timely colorectal cancer screening at Lincoln Medical Center, a large, urban public hospital in one of the nation's poorest census tracts. We conducted a retrospective analysis of all colonoscopies performed over an 11-month period, during which a multi-pronged intervention to increase the number of screening colonoscopies took place. Two “patient navigators” were hired during the study period to provide continuity for colonoscopy patients. A Direct Endoscopic Referral System (DERS) was also implemented. Enhancements to the gastrointestinal (GI) suite were also made to improve operational efficiency. Immediately following the introduction of the patient navigators, there was a dramatic and sustained decline in the broken appointment rates for both screening and diagnostic colonoscopy (from 67% in May of 2003 to 5% in June of 2003). The likelihood of keeping the appointment for colonoscopy after the patient navigator intervention increased by nearly 3-fold (relative risk = 2.6, 95% CI 2.2–3.0). The rate of screening colonoscopies increased from 56.8 per month to 119 per month. The screening colonoscopy coverage provided by this facility among persons aged 50 and over in surrounding Zip codes increased from 5.2 to 15.6% (RR 3.0, 95% CI 1.9–4.7). Efforts to increase the number of screening colonoscopies were highly successful, due in large part to the influence of patient navigators, a streamlined referral system, and GI suite enhancements. These findings suggest that there are significant health-care system barriers to colonoscopy that, when addressed, could have a significant impact on screening colonoscopy rates in the general population. Nash is with the Center for Urban Epidemiologic Studies, The New York Academy of Medicine, New York, NY, USA, the Department of Epidemology, International Center for AIDS Care and Treatment Programs, Columbia University, Mailman School of Public Health, New York, NY, USA; Azeez is with the Department of Gastroenterology, Lincoln Medical Center, Bronx, NY, USA; Vlahov is the Director of the Center for Urban Epidemiologic Studies at the New York Academy of Medicine, New York, NY, USA; Schori is with the Office of the Medical Director, Lincoln Medical Center, Bronx, NY, USA. An erratum to this article can be found at     

Unprotected Sexual Behavior Among Heterosexual HIV-Positive Injection Drug Using Men: Associations by Partner Type and Partner Serostatus

Few studies have examined sexual risk behaviors of HIV-positive, heterosexual, injection drug using (IDU) men. We investigated such behaviors and associations with risk among sexually active, HIV-positive IDU men who reported only female sex partners in the 3 months prior to baseline interview. We examined associations separately for four non-exclusive groups of men by crossing partner type (main or casual) and partner serostatus (HIV-positive or HIV-negative/unknown). Of 732 male participants, 469 (64%) were sexually active with only female partners. Of these 469 men, 155 (33%) reported sex with HIV-positive main partners, 127 (27%) with HIV-negative or unknown serostatus main partners, 145 (31%) with HIV-positive casual partners, and 192 (41%) with HIV-negative/unknown serostatus casual partners. Significant multivariate associations for unprotected sex with HIV-negative or unknown serostatus main partners were less self-efficacy to use condoms, weaker partner norms supporting condoms, and more negative condom beliefs. Similar correlates were found for unprotected sex with HIV-positive main and casual partners. In addition, alcohol or drug use during sex was a significant correlate of unprotected sex with HIV-positive main partners, while depression was significant for HIV-positive casual partners. For unprotected sex with HIV-negative/unknown status casual partners, self-efficacy for condom use, sex trade, and education were significant multivariate correlates. A combination of broad and tailored intervention strategies based on the relationship pattern of men's lives may provide the most benefit for reducing unprotected sex with female partners.Purcell and Mizuno are with the Division of HIV/AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA, USA; Metsch is with the University of Miami, Miami, FL, USA; Garfein is with the Department of Family and Preventive Medicine, University of California at San Diego, San Diego, CA, USA; Tobin is with the Bloomberg School of Public Health, Baltimore, MD, USA; Knight is with the University of California at San Francisco, San Francisco, CA, USA; Latka is with the Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA.The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

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.     

Updating disaster plans: a tale of three hospitals

Three hospitals that were struck by disaster in 1977 have undertaken major revision of their disaster plans as a result of unexpected problems that occurred during the crises. Lee Hospital, Johnstown, PA, is installing a tough "floodproofing" system; Jewish Hospital and Medical Center, Brooklyn, NY, and Bellevue Hospital Center, New York City, are revamping their emergency electrical systems.     

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.     

Promotion of family enrollment in an urban family practice residency program

Although a basic goal of family practice is to provide care for all members of the family, few studies have been done to test the ease of accomplishing this goal. At the Downstate Medical Center Department of Family Practice in Brooklyn, New York, an attempt was made to increase family enrollment by introducing several educational interventions directed at patients and resident physicians. Family enrollment levels were documented during a study period from June 1981 to September 1982, and again in June 1984. Both before and after the intervention efforts, family enrollment levels remained the same. It was concluded that the educational interventions used were unsuccessful in both short-term and long-term follow-up. Only one subgroup that participated in a specific educational intervention (patient orientation groups) showed an increase in family enrollment.     

The Establishment of the School of Public Health at the State University of New York,Downstate Medical Center: The First Nationally Accredited School of Public Health in a Public University in New York City

The State University of New York (SUNY), Downstate Medical Center initiated a Master of Public Health (MPH) degree program in July 2001 following planning efforts that began in 1995. Twelve students entered the program in June 2002, and currently some 110 MPH students and 12 Doctor of Public Health (DrPH) students are enrolled. This article describes the long and complex process of transforming the original MPH degree program, with its single focus on urban and immigrant health, with a student enrollment of 12 and 8 full-time faculty, into a school of public health with a large student enrollment of 122 students, 25 full-time faculty, five MPH degree tracks, and four DrPH degree tracks. The process of establishing the SUNY Downstate School of Public Health in 2009 from its inception as an MPH program in 2001 spanned a period of 8 years. This process was guided by a commitment to two basic principles. The first was to maintain the original 2005 program accreditation by the Council on Education for Public Health (CEPH). The second was to sequentially secure accreditation for all subsequent four MPH and four DrPH degree tracks through CEPH’s procedure of substantive change approval. This policy assured continuous national CEPH accreditation of the original Urban and Immigrant Health MPH degree track and all added degree programs. The 5-year period following the initial CEPH accreditation of the MPH program in 2005 was one of intense development during which all of the essential elements for CEPH accreditation of a school of public health were put into place. This rapid development was made possible by the vision and full support of Downstate’s president, John C. LaRosa, MD, FACP, and the dedicated efforts of many. This included the students, faculty, staff, and administrators of the School of Public Health, the school’s Community Advisory Group, several external advisors, and many in the medical center’s Central Administration, College of Medicine, School of Graduate Studies, College of Nursing, College of Health Related Professions, and the University Hospital of Brooklyn. From the very beginning of the planning phase for an MPH program and through the ultimate accreditation of the School of Public Health in 2010, broad participation was solicited from all major units in the medical center. Thus, the MPH program became a center-wide initiative and not merely that of the College of Medicine’s Department of Preventive Medicine and Community Health. This broad participation has been continuously maintained through the involvement of leaders of other medical center academic units and the University Hospital of Brooklyn in the program’s and then the school’s standing and ad hoc committees, and in other activities as well. Similarly, community representation has been maintained, some through formal linkages relevant to the practical field experiences required of all students. In October 2010, the Board of Councilors of CEPH accredited the SUNY Downstate School of Public Health for a 5-year period through 31 December 2015. The accreditation of the school was a major milestone for Downstate, Brooklyn, and New York City. The SUNY Downstate School of Public Health is the first CEPH accredited school of public health in the history of Brooklyn, and only the second such school in New York City. It is also the first CEPH accredited school of public health at a publicly supported university in New York City. The school has already had a major impact on improving the health and well-being of the people of Brooklyn through its numerous collaborative community-based health promotion and disease prevention programs.     

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.     

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.     

Influence of Nativity Status on Breast Cancer Risk Among US Black Women

Black women are at increased risk for breast cancer mortality. The black category is assumed to be homogeneous, an assumption that may be misleading. This study aims to examine the relationship between nativity and breast cancer risk factors among women identified as black. A sample of 236 black women over 18 years of age in Brooklyn, New York, was recruited. Data were collected on race/ethnicity, breast cancer risk factors, and other sociodemographic, behavioral, and early life experience factors. Logistic regression analyses were used to estimate prevalence ratios for association between nativity and breast cancer risk factors. US-born blacks were more likely to be unemployed, smoke, not breastfeed, and breastfeed for a shorter duration than foreign-born blacks (all p≤0.01). Foreign-born blacks were more likely to have parents who achieved at least a high school education (p<0.05). After adjustment for smoking, employment, and parental education, US-born blacks were twice as likely to never breastfeed (PR 2.2, 95% CI: 1.1, 4.46) compared to foreign-born blacks. Among women who breastfed, US-born blacks were also less likely to breastfeed for 6–11 months or more than 12 months, but these associations were not statistically significant. Because lactation reduces breast cancer risk and is a leading modifiable risk factor, understanding its variation within black women will help physicians and public health practitioners to target patient counseling and education of breast cancer risk. Borrell, Castor, and Terry are with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Conway is affiliated at Adelphi University, New York, NY, USA.     

Name-based notification bill sails through New York Senate

The New York Senate approved a bill requiring public health officials to notify spouses, sexual partners, and needle-sharing partners of HIV-positive people, that they have been exposed to the virus. Under S. 4422-A, physicians are required to report HIV-positive patients, by name, to the State Department of Health, so as to begin the process of partner notification and statewide HIV case surveillance. AIDS activists consider the new law coercive and less effective than growing programs that reinforce safer-sex messages. The current notification system, which allows the physician or patient the option of notifying the State Health Department, has sometimes been assessed as a failure. A compromise is being considered that involves telling the State Department the names of the partners to contact, while protecting the confidentiality of the HIV-positive patient by assigning the patient a unique identifier number. This would allow tracking of the HIV surveillance data, without comprising the confidentiality of the HIV-positive patient.     

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.     

Screening for cervical and breast cancer among Caribbean immigrants

A screening program for cervical and breast cancer, focused on immigrant Caribbean women, was carried out at neighborhood sites (churches, schools, etc.) in a low-income area of Brooklyn, New York.The yield of abnormal Pap tests was 13.3/1000 women screened; the yield of breast cancer was 2.2/1000 women examined. Approximately half of the Haitian immigrants (N=361) had no prior Pap test, compared to one-quarter of the English-speaking Caribbean immigrants (N=228) and one-tenth of the U.S.-born Black women (N=264). Only 47% of Haitian women had a regular source of health care compared to 74% of the English speaking Caribbean women and 83% of the U.S.-born Black women. Haitian women were much less likely to practice breast self-examination or to use contraception than were U.S.-born Black women.This program reveals significant needs for preventive health services among low-income Caribbean immigrant women, and demonstrates that selective neighborhood-site programs can be effective in reaching those in need.Rachel G. Fruchter, MPH, PhD, is Assistant Professor, Department of Obstetrics and Gynecology. Carolyn Wright, MS, is Community Health Educator/Coordinator, Department of Preventive Medicine and Community Health. Barbara Habenstreit, MA, is Assistant to the Chairman, Department of Preventive Medicine and Community Health. Jean Claude Remy, MD, is Assistant Professor, Department of Obstetrics and Gynecology. John G. Boyce, MD, is Professor, Department of Obstetrics and Gynecology. Pascal James Imperato, MD, MPH & TM is Professor and Chairman, Department of Preventive Medicine and Community Health, State University of New York, Downstate Medical Center.This research was supported by grants from the New York Community Trust and the Morgan Guaranty Trust Company of New York Charitable Trust     

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.     

Traditional Physical Activity Indexes Derived from the Harvard Alumni Activity Survey Have Low Construct Validity in a Lower Income,Urban Population

The purpose of this study is to investigate the construct validity of the Harvard Alumni Activity Survey (HAAS) in an urban, lower income population. Data were collected from 192 smokers enrolled in an antioxidant micronutrient trial. Activity data were compared to body mass index (BMI), diastolic, and systolic blood pressure. The traditional physical activity index (PAI), using data on stair climbing, walking, and sports, was calculated including and excluding body mass. A new scale, the total weekly activity (TWA) scale, was derived from other questions on the HAAS. The PAI scale calculated with body mass was unassociated with BMI and blood pressure. The PAI scale calculated without body mass was unassociated with BMI and systolic blood pressure but was associated with diastolic blood pressure (Beta = −0.001, p = 0.03). The TWA scale was associated with BMI (Beta = −0.01, p = 0.01), diastolic (Beta = −0.03, p = 0.01), and systolic blood pressure (Beta = −0.04, p = 0.01). A one standard deviation change in the TWA scale is predicted to be equivalent to a change of 0.99 BMI units, 2.97 mmHg of diastolic blood pressure, and 3.96 mmHg of systolic blood pressure. This work suggests that the TWA scale has greater construct validity than the traditional PAI scale in this population. Rundle is with the Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA; Hagins is with the Division of Physical Therapy, School of Health Professions, Long Island University, Brooklyn Campus, Brooklyn, NY, USA; Orjuela, Mooney, Kim, and Perera are with the Department of Environmental Health Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA.     

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.     

Coburn presses HHS to enforce spousal notification law. Department of Health and Human Services

Representative Tom Coburn of Oklahoma is demanding that the Department of Health and Human Services (HHS) investigate whether States are making good-faith efforts to comply with the spousal notification programs mandated by the Ryan White CARE Act amendments. Coburn is threatening legal action to compel enforcement of the provision. When Congress reauthorized the notification program in 1996, they added language that barred HHS from awarding grants to a State unless it attempted to notify spouses when their partners tested positive. Coburn's contention is that States like New York, California, and New Jersey, which have about 40 percent of the total HIV cases in the country, do not notify spouses without the express voluntary consent of the HIV-positive person. The Centers for Disease Control and Prevention interprets the language of the notification program differently and is working to improve both data collection and prevention services directed toward spouses.     

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.