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     

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.     

Health services use among the elderly under alternative health service delivery systems

This article compares patterns of health care utilization for hospitalizations and ambulatory care in a sample of 1855 urban, elderly, community residents who report obtaining their health care from one of four types of arrangements: a fee-for-service (FFS) physician, a hospital-based health maintenance organization, a network model HMO, or a preferred provider organization (PPO). Utilization rates reported by respondents at six month intervals over three years were adjusted for health and socioeconomic characteristics of enrollees. PPO plan members consistently have mean and total lengths of hospital stay one-third to one-half those of the others. Although rates of use of particular categories of ambulatory care vary across systems of care, total ambulatory care rates are highest for network model HMO plan members. Specific features of alternative delivery systems, rather than general model types, may have an impact on utilization rates and the costs of care.Cynthia Thomas, Ph.D. is Senior Research Associate and Howard R. Kelman, Ph.D. is Director, Division of Health Services Organization and Policy, Department of Epidemiology and Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York 10467. Requests for reprints should be addressed to: Cynthia Thomas, Ph.D., Montefiore Medical Center, 111 East 210th Street, Bronx, N.Y. 10467. This work was supported by grants from the National Institute on Aging (P01 AG03424) and (R01 AG08125).The authors would like to thank John Wenston for data processing and programming support, Alicia Thomas for research assistance, and Christine M. Filardi for secretarial support.     

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.     

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.     

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]     

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.     

Transitions between community and nursing home residence in an urban elderly population

Over the course of a three year observation and study period, some 6% of a representative community residing urban elderly population were admitted to nursing homes. Nearly half of this group were still living in nursing homes at the end of this observation period. One third had died after entering the nursing home, and the remaining people had returned to their own homes in the community. These three groups had significantly different mean lengths of stay in nursing homes; nearly two years for those whose stays were more permanent, 50 days for those whose stays were short-term, and 153 days on average for those who died following admission.At baseline, the three groups also tended to have different patterns of health, functional and social characteristics. The short term stayers and those who died following admission to a nursing home differed from respondents who did not enter nursing homes—primarily in terms of prior living arrangements and levels of social support. The permanent stayers differed from the two other nursing home sub-groups, and from community residents, in that they tended to be older and more functionally and mentally impaired. However, at baseline they appeared at less risk to expire than those people who later died following admission to nursing homes.Clinical and research implications based on these findings are discussed.Howard R. Kelman, Ph.D. is Director, and Cynthia Thomas, Ph.D. is Senior Research Associate, Division of Health Services Organization and Policy, Department of Epidemiology and Social Medicine, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York 10467This work was supported by grants PO1 AGO3424 and RO1 AGO8125 from the National Institute on Aging     

Mental health systems and services in the United States

This paper discusses mental health policies, mental health services, awareness of these services, the evaluation of such services and how mental health care is financed in this country. Dr. David Baskin, Director of Evaluation and Research at the Bronx-Lebanon Hospital Center/Crotona Park Community Mental Health Center, a member of the faculty of the Albert Einstein College of Medicine, has lectured on the epidemiology of mental disorders and conducted numerous research projects in the field of mental health.     

Sleep problems in the community elderly as predictors of death and nursing home placement

In 1984–85, 1855 elderly residents of an urban community responded to a comprehensive baseline interview that included questions regarding an extensive set of sleep characteristics and problems. During the subsequent 3 1/2 years of follow-up, 16.7% of the respondents died and 3.5% were placed in nursing homes. The predictive significance of each sleep characteristic for mortality and for nursing home placement was determined separately for males and females, using Cox proportional hazards models. Selected demographic and psychosocial variables were also entered into the models. Age, problems with activities of daily living (ADL), self-assessed health, income, cognitive impairment, depression and whether respondents were living alone were controlled for statistically.Of the many variables analyzed, in males insomnia was the strongest predictor of both mortality and nursing home placement. For mortality, the relative hazard associated with insomnia exceeded the hazards associated with age, ADL problems, fair-poor health and low income. For nursing home placement, the hazard associated with insomnia exceeded that associated with cognitive impairment. The relationships of insomnia to mortality and nursing home placement were U-shaped, with a worse outcome if insomnia complaints over the preceding 2 weeks were either prominent (numerous or frequent) or absent. For females, insomnia was a borderline predictor of mortality and did not predict nursing home placement at all. Symptoms of the restless legs syndrome predicted mortality for females in some Cox regression models. Reported sleep duration, symptoms of sleep apnea and frequent use of hypnotic drugs did not predict mortality or nursing home placement in either sex.Charles P. Pollak, M.D. is Director Institute of Chronobiology Department of Psychiatry New York Hospital-Cornell Medical Center White Plains, New York; Deborah Perlick, Ph.D. is Supervising Psychologist in Neuropsychology Department of Psychiatry Montefiore Hospital and Medical Center New York, New York; Jerome P. Linsner, Ph.D. is Research Associate Institute of Chronobiology Department of Psychiatry New York Hospital-Cornell Medical Center White Plains, New York; John Wenston, M.A. is Research Associate Department of Epidemiology and Social Medicine Montefiore Hospital and Medical Center New York, New York; Frank Hsieh, Ph.D. is Assistant Clinical Professor Department of Epidemiology and Social Medicine Albert Einstein College of Medicine New York, New YorkThis research was supported by grant numbers PO1 AG03424 and RO1 AG08125 from the National Institute on Aging.     

A neonatal preventive intervention study: Issues of recruitment and retention

Intervention to prevent negative mental health outcomes in families of ill and premature newborns is an important part of neonatal care. This study addresses the factors which influence participation in a parent support group for parents of ill and premature newborns. Demographic, social support, and infant health data were examined to determine how support group participants and nonparticipants differed. In addition, efforts at enhancing recruitment and retention into support groups were examined. Results showed participants in the support group to have less healthy infants with longer hospital stays than nonparticipants. Participants reported more favorable financial situations, slightly higher incomes and less social support as measured by fewer contacts with family and friends than nonparticipants. Recommendations for future intervention research are discussed.The authors acknowledge the help of the group leaders who volunteered to participate in the study, as well as the exceptional efforts of Susan Grossbard in recruitment of subjects. In addition, the support and assistance of Drs. Ruth Stein, Henry Ireys and Dorothy Jessop throughout the research project is greatly appreciated.The authors are affiliated with the Preventive Intervention Research Center for Child Health, the Division of Neonatology, and the Low Birthweight Infant Follow-up & Evaluation Program of the Department of Pediatrics, Albert Einstein College of Medicine—Montefiore Medical Center (supported in part by Grant #P50-MH38280 from the Branch for Prevention Research of the National Institute of Mental Health).     

Implementing a Routine, Voluntary HIV Testing Program in a Massachusetts County Prison

Although U.S. prison inmates have higher rates of HIV infection than the general population, most inmates are not routinely tested for HIV infection at prison entry. The study objective was to implement a routine, voluntary HIV testing program in a Massachusetts county prison. During admission, inmates were given group HIV pre-test counseling and were subsequently offered private HIV testing. This intervention was compared to a control period during which HIV testing was provided only upon inmate or physician request. Between November 2004 and April 2005, 1,004 inmates met inclusion criteria and were offered routine, voluntary HIV testing. Of these, 734 (73.1%) accepted, 2 (0.3%) were HIV-infected, and 457 (45.5%) had been tested for HIV in the previous year. The testing rate of 73.1% was significantly increased from the rate of 18.0% (318 of 1,723) during the control period (p<0.001). Among the inmates tested for HIV in the prior year, 78.2% had received their last HIV test in the prison setting. Careful attention should be paid to prevent redundancy of testing efforts in the prison population. Implementing a routine HIV testing program among prison inmates greatly increased testing rates compared to on-request testing. Liddicoat is with the Department of Medicine, Greater Los Angeles Veterans Administration, Mail 111G, 11301 Wilshire Boulevard, Los Angeles, CA 90073, USA; Zheng, Freedberg, and Walensky are with the Division of General Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Freedberg and Walensky are with the Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Zheng, Freedberg, and Walensky are with the Partners AIDS Research Center, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Internicola and Golan are with the Suffolk County House of Corrections, Boston, MA, USA; Golan is with the Department of Infectious Disease, Tufts University Medical School, Boston, MA, USA; Rubinstein is with the HIV/AIDS Bureau, Massachusetts Department of Public Health, Boston, MA, USA; Werner and Kazianis are with the Massachusetts State Laboratory Institute, Boston, MA, USA.     

Beliefs about methadone in an inner-city methadone clinic

Despite being considered both the most effective treatment for beroin addiction and an essential tool in the prevention of buman immunodeficiency virus (HIV), methadone maintenance (MM) is often held in low esteem by beroin addicts—even those in MM treatment. This survey examined current beliefs and attitudes about MM of patients at an inner-city clinic, and the personal experience and attitudes of these patients with this treatment. Consenting patients in a methadone clinic serving a poor population with high rates of human immunodeficiency virus infection were queried about their attitudes toward and beliefs about methadone using a 16-item questionnaire. Over 2 days, 315 questionnaires were completed (acceptance rate 40%), totaling 32% of the 1000 clinic patients. Nearly 80% believed that methadone bad a positive effect on bis or ber life, but 80% were certain or unsure as to whether methadone is bad for one's bealth, and a similar percentage (80%) believed that discontinuing methadone was an important goal. Patients continue to have strongly negative attitudes toward and beliefs about methadone despite their acknowledgement that methadone has been very positive for them as individuals. As a result, many patients leave MM treatment prematurely, and there are usually unfilled slots in MM programs in New York City, even while continued need exists (e.g., less than 25% of the beroin addicts in the city are in treatment). The restrictive nature of many MM programs may account for these attitudes and beliefs. Weill Medical College of Cornell University; and Dr. Drucker is with Montefiore Medical Center/Albert Einstein College of Medicine.     

Mental health systems and services abroad

A cross-national survey of forty-two countries and provinces was undertaken to compare mental health policies, mental health services, awareness of these services, the evaluation of such services and how mental health care is financed. Notable differences were found between respondents and these differences could not always be accounted for in terms of the level of the countries economic development. Discussions of trends are detailed and suggestions for future inquiry are proffered. Notes:This is a follow-on article to Dr. Baskin's article on “Mental Health Systems and Services in the United States” that appeared in the Fall 1981 issue. Dr. David Baskin, Director of Evaluation and Research at the Bronx-Lebanon Hospital Center/Crotona Park Community Mental Health Center, a member of the faculty of the Albert Einstein College of Medicine, has Icctured on the epidemiology of mental disorders and conducted numerous research projects in the field of mental health.     

Dedicated CM coordinates discharges for patients

Montefiore Medical Center in Bronx, NY, has a complex case manager who coordinates post-discharge options for uninsured patients with complex needs. The initiative frees up unit case managers and social workers to manage the care of less complex patients. The hospital has an arrangement with a community-based organization to provide a safe living environment for patients who are homeless and need post-acute services. A complex care advisory team reviews patients with post-discharge issues and makes a recommendation to the hospital's administration.     

Mental illness and the working poor

This paper addresses the following three issues: The assessment of the supply and utilization of mental health facilities and services by the “working poor”, interactions within the general health/mental health services system, which influence the care of the “working poor” who have mental disorders, and the assessment of the need for mental health services by the “working poor”. Dr. David Baskin, previously Director of Evaluation and Research at the Bronx-Lebanon Hospital Center/Crotona Park Community Mental Health Center, is currently the Associate Director of the Soundview—Throgs Neck CMHC, an agency of the Albert Einstein College of Medicine. He has been a regular contributor to the Journal for the past several years. This is his fourth article.     

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     

Tripling of Methamphetamine/Amphetamine Use among Homeless and Marginally Housed Persons, 1996–2003

Methamphetamine/amphetamine (MA)-related morbidity and mortality has been increasing in the United States. MA use is associated with high-risk sexual behavior and syringe-sharing practices. Homeless and marginalized housed persons (H/M) have high rates of substance use and mental health disorders. Little is known about trends of MA use among the H/M. The objective of this study was to quantify increases in MA use among H/M in San Francisco and to determine which demographic and behavioral subgroups have experienced the greatest increases in MA use. We conducted serial cross-sectional population-based studies in three waves: 1996–1997, 1999–2000, and 2003 and studied 2,348 H/M recruited at shelters and lunch lines. The main outcome was self-reported current (30-day) MA use. We found a tripling of current MA use among H/M persons from 1996 to 2003, with a sevenfold increase in smoked MA use. MA use doubled to tripled in most demographic and behavioral subgroups, whereas it quadrupled in those under age 35, and there was a fivefold increase among HIV-infected persons. The increase in MA use among H/M places a vulnerable population at additional increased risk for HIV infection and MA-use related morbidity and mortality. Among HIV-infected H/M, the increase in MA use has important public health implications for the development and secondary transmission of drug-resistant HIV caused by synergistic neurocognitive decline, poor adherence to HIV medications, and increased sexual risk behavior. Clinicians caring for H/M persons should inquire about MA use, refer interested MA users to MA dependence treatment programs and provide targeted HIV sexual risk reduction counseling. For HIV-infected H/M MA users, clinicians should closely monitor adherence to HIV or other chronic medications, to avoid unnecessary morbidity and mortality. Further research is needed to elucidate the most effective prevention and treatment for MA use and dependence among the H/M. Das-Douglas and Bangsberg are with the Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, CA, USA; Das-Douglas, Bangsberg, and Hahn are with the Epidemiology and Prevention Interventions Center, Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA; Das-Douglas and Bangsberg are with the Center for AIDS Prevention Studies, University of California, San Francisco, CA, USA; Colfax is with the Epidemiology Section, AIDS Office, San Francisco Department of Public Health, San Francisco, CA, USA; Moss is with the Epidemiology and Biostatistics, University of California, San Francisco, 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     

An invisible barrier to integrating HIV primary care with harm reduction services: philosophical clashes between the harm reduction and medical models

Overall AIDS mortality in the United States has declined in recent years, but declines have not been consistent across all populations. Due to an array of barriers to care, minorities and poor people who are active substance users have not benefited as others have from advances in the treatment of HIV disease. One way to address this problem is to integrate HIV primary care into harm reduction programs that already effectively serve this population. Such collaborations, however, are difficult to initiate and sustain. Philosophical differences between the medical model and the harm reduction model, which often remain invisible to the parties involved, underlie these difficulties. This article addresses the issue by describing a partnership in the Bronx, NY, between CitiWide Harm Reduction Inc. (CitiWideHR) and the Montefiore Medical Center. It focuses specifically on the sources of philosophical differences between models, and briefly assesses the potential for successful collaborations of this sort.