Biomedical subjects

Roger B Davis

Publications and source records attributed to Roger B Davis.

At least 55 records · Page 3Linked to original sources

PubMed2004

Creation of an innovative inpatient medical procedure service and a method to evaluate house staff competency.

INTRODUCTION: Training residents in medical procedures is an area of growing interest. Studies demonstrate that internal medicine residents are inadequately trained to perform common medical procedures, and program directors report residents do not master these essential skills. The American Board of Internal Medicine requires substantiation of competence in procedure skills for all internal medicine residents; however, for most procedures, standards of competence do not exist. OBJECTIVE: 1) Create a new and standardized approach to teaching, performing, and evaluating inpatient medical procedures; 2) Determine the number of procedures required until trainees develop competence, by assessing both clinical knowledge and psychomotor skills; 3) Improve patient safety. DESIGN: A Medical Procedure Service (MPS), consisting of select faculty who are experts at common inpatient procedures, was established to supervise residents performing medical procedures. Faculty monitor residents' psychomotor performance, while clinical knowledge is taught through a complementary, comprehensive curriculum. After the completion of each procedure, the trainee and supervising faculty member independently complete online questionnaires. RESULTS: During this pilot program, 246 procedures were supervised, with a pooled major complication rate of 3.7%. 123 thoracenteses were supervised, with a pneumothorax rate of 3.3%; this compares favorably with a pooled analysis of the literature. 87% of surveyed house staff felt the procedure service helped in their education of medical procedures. CONCLUSIONS: The "see one, do one, teach one" model of procedure education is dangerously inadequate. Through the development of a Medical Procedure Service, and an associated procedure curriculum and a mechanism of evaluation, we hope to reduce the rate of complications and errors related to medical procedures and to determine at what point competency is achieved for these procedures.

Boston↗

PubMed2004

Obesity and breast cancer screening.

BACKGROUND: Compared to normal weight women, women with obesity have higher mortality from breast cancer but are less often screened. OBJECTIVES: To examine the relation between mammography use and weight category and to examine the influence of race, illness burden, and other factors on this relationship. DESIGN AND SETTING: The 1998 National Health Interview Survey, a U.S. civilian population-based survey. PARTICIPANTS: Five thousand, two hundred, and seventy-seven women ages 50 to 75 years who responded to the Sample Adult and Prevention questionnaires. MEASUREMENTS: Mammogram use in the preceding 2 years. RESULTS: Among 5277 eligible women, 72% reported mammography use. The rate was 74% among white women and 70% among black women. Among white women, mammogram use was lowest in women with a body mass index (BMI) greater than 35 kg/m(2) (64% to 67%). After adjusting for sociodemographic factors, health care access, medical conditions, hospitalizations, and mobility status, higher BMI was associated with lower screening among white women, P =.02 for trend; the relative risk (RR) for screening in moderately obese white women (BMI, 35 to 40 kg/m(2)) was 0.83 (95% confidence interval [CI], 0.68 to 0.96) compared to normal weight white women. Compared to normal weight black women, mammography use was similar or higher in overweight (BMI, 25 to 30 kg/m(2); RR, 1.19; 95% CI, 1.01 to 1.32), mildly obese (BMI, 30 to 35 kg/m(2); RR, 1.22; 95% CI, 0.98 to 1.39), and moderately obese black women (RR, 1.37; 95% CI, 1.37 to 1.50) after adjustment. The P value for the race-BMI interaction was.001. Results for white and black women were unchanged after additional adjustment for psychological functioning and health habits. CONCLUSION: Among white women, those with higher BMI were less likely to undergo breast cancer screening than normal weight women. This relationship was not seen in black women. Our findings were not explained by differences in sociodemographic factors, health care access, illness burden, or health habits. More research is needed to determine the reasons for these disparities so that appropriate efforts can be made to improve screening.

Black or African American↗

PubMed2004

Factors that influence patient response to requests to change to a unified restrictive formulary.

OBJECTIVE: To determine factors that influence patient willingness to accept a medication change to a unified, restrictive formulary. DESIGN: Prospective cohort study. SETTING: University-affiliated hospital-based primary care internal medicine practice. PATIENTS/PARTICIPANTS: Two hundred ninety-seven members of a managed care plan who had received a prescription for a nonformulary medication in the previous 4 months and whose primary care physician approved a conversion to a formulary medication. INTERVENTIONS: Clinical nurses invited patients to change to a formulary medication at the time of a telephone refill request based on a standard script. MEASUREMENTS AND MAIN RESULTS: The overall conversion rate to the formulary medication was 59.8%. Seventy-four percent of patients who requested a refill by telephone converted to the formulary (odds ratio [OR], 2.24; 95% confidence interval [CI], 1.02 to 4.72). Patient age (OR, 1.03; CI, 1.01 to 1.05) and male gender (OR, 2.00; CI, 1.09 to 3.67) were each significant correlates of conversion. After adjustment in a multivariable model, only telephone refill request (adjusted OR, 2.31; CI, 1.07 to 4.97) and age (adjusted OR, 1.03; CI, 1.01 to 1.06) remained significant. Among the patients who made a telephone refill request, those who converted were more likely to completely trust their physician's judgment (P=.04) and to trust their physician to put their health over cost concerns (P=.05). Formulary conversion reduced costs beginning 3 months after the conversion date. CONCLUSIONS: A protocol for encouraging conversion to a unified formulary at the point of a telephone refill request increases formulary compliance rates and reduces medication costs. Patients who decline to convert medications are less likely to trust their physician.

Adult↗

PubMed2004

Assessing the value of weight loss among primary care patients.

BACKGROUND: Modest weight loss of 10% of baseline weight is beneficial and achievable for overweight and obese patients. However, whether primary care patients value modest weight loss is unclear. OBJECTIVE: To quantify the value patients place on modest weight loss. DESIGN: Cross-sectional telephone survey. SETTING: Patients at a large hospital-based primary care practice. PARTICIPANTS: Three hundred sixty-five primary care patients (60% response rate). MEASUREMENTS: Utilities or value for weight loss estimated from willingness to risk death or trade time in exchange for losing different levels of weight (weight loss in pounds equivalent to a 5%, 10%, and 20% reduction in initial weight or to achieve a body mass index [BMI] of 25 kg/m2) using the standard gamble and time tradeoff formats. RESULTS: Of respondents, 15% of overweight (BMI, 25 to 29.9 kg/m2) and 42% of obese patients (BMI > or = 30 kg/m2) believed they needed to lose more than 10% of their weight to derive any health benefits. However, 18% of overweight and 33% of obese patients were willing to risk death to lose 10% of their weight. Patients with higher BMI valued higher degrees of weight loss. Among the overall sample, the utilities derived using standard gamble were 0.95 for current weight, 0.96 for 5% weight loss, 0.97 for 10% weight loss, and 0.98 for 20% weight loss; among obese patients, utilities were 0.88, 0.91, 0.93, and 0.96, respectively. Utilities derived using time tradeoff were lower but correlated with utilities derived from standard gamble. Utilities did not vary by education, gender, race, having comorbidities, or smoking. CONCLUSIONS: Many primary care patients value modest weight loss. The value placed on loss of 10% body weight among obese patients where utility improved from 0.88 to 0.93 is similar to recovery from major depression. Nevertheless, the majority of patients still do not highly value modest weight loss. Clinicians should emphasize the health benefits of modest weight loss when counseling about weight.

Body Mass Index↗

PubMed2004

Breast cancer screening in women aged 80 and older: results from a national survey.

OBJECTIVES: To estimate the national rates of mammography screening in women aged 80 and older and examine the relationship between health status and screening within the previous 2 years. DESIGN: Population-based survey. SETTING: United States. PARTICIPANTS: Eight hundred eighty-two women aged 80 and older who responded to the 2000 National Health Interview Survey, representing an estimated 3.83 million noninstitutionalized women nationally. MEASUREMENTS: Screening mammography, disease burden, and functional status were assessed using a questionnaire. RESULTS: Of the 882 women, 41.5% were aged 85 and older; 19.6% had two or more significant diseases; and 12.1% were dependent in at least one activity of daily living (ADL). More than half (50.8%) had received a screening mammogram within the previous 2 years. Women with two or more significant diseases were less likely to have received screening than those without significant disease, but the difference was not statistically significant (43.9% vs 54.0%, P=.152). Women dependent in at least one ADL were less likely to receive screening mammography than women without functional impairment (37.2% vs 55.9%, P<.001). After adjustment, the likelihood of screening remained lower in women with two or more significant diseases (adjusted odds ratio (AOR)=0.63, 95% confidence interval (CI)=0.40-1.05) and in women with at least one ADL dependency (AOR=0.44, 95% CI=0.22-0.88). Of 294 women likely to have life expectancies of less than 5 years because of poor health, 39.4% received screening mammography. CONCLUSION: More than half of women aged 80 and older in the United States receive screening mammograms. Nearly 40% of women very unlikely to benefit because of poor health received screening mammography.

Activities of Daily Living↗

PubMed2004

Racial and ethnic differences in utilization of health services in patients with diabetes enrolled in medicaid.

We evaluated racial and ethnic differences in use of medical care between patients with diabetes enrolled in Medicaid and explored whether differences varied by state Medicaid program. Using data from 137,006 patients we created a multivariable Poisson regression model to examine the effect of race on ambulatory care visits, emergency ward visits, and hospitalization rates for patients with diabetes mellitus enrolled in three state Medicaid programs. We found significant differences in service use between groups, which varied depending on state. For example, black patients compared with whites had significantly fewer outpatient visits but more hospitalizations in New Jersey; by contrast, blacks had higher outpatient visit rates and lower hospitalization rates in Georgia. Racial and ethnic differences in health service use among Medicaid enrollees were not consistent across states, suggesting that local factors, including varied Medicaid policies, may affect racial and ethnic differences in use of health care services.

Diabetes Mellitus↗

PubMed2004

Modelling the ability of risk adjusters to reduce adverse selection in managed care.

Population-based risk adjustment, as applied to reimbursement in managed care settings, may reduce pressures for adverse selection by managed care organisations. Using insurance claims data from 184 340 plan members, we compared the performance of three risk-adjustment methods. We present a model for measuring the impact of risk adjustment on the likelihood that individual members will be at risk for adverse selection. These results are compared with resource allocation based on age/sex. The predictive ability of alternative allocation schemes increased from an R(2) of 1.2% for age-sex allocation to 11.4% based on risk adjustment using diagnostic cost groups. However, the impact of risk adjustment on the proportion of members at risk for adverse selection was small. At an absolute threshold loss of $US2400 per year, 8.3% to 8.6% of members were at risk for adverse selection compared with 9.3% based on age-sex allocation. The limited impact of risk adjustment on the likelihood of adverse selection suggests that other strategies for reducing adverse selection may be required.

Adolescent↗

PubMed2003

Physicians' decisions to override computerized drug alerts in primary care.

BACKGROUND: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care. METHODS: We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred. RESULTS: Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate. CONCLUSIONS: Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.

Adult↗

PubMed2003

How physicians perceive hospitalist services after implementation: anticipation vs reality.

OBJECTIVE: To determine whether internists' attitudes toward the hospitalist model change after implementation of a new inpatient service. DESIGN: Cross-sectional surveys performed in 1998 and 2000. SETTING: Tertiary care hospital in Boston, Mass. SUBJECTS: A total of 236 internal medicine board-certified physicians affiliated with Beth Israel Deaconess Medical Center. MAIN OUTCOME MEASURES: Responses to survey items regarding attitude toward inpatient care and the hospitalist model. We used multivariable models to determine factors associated with physician responses. RESULTS: Of physicians surveyed in 2000, 236 (69%) responded; 145 (61%) had also responded in 1998. The mean (SD) age of respondents was 46.4 (10.8) years; 157 (66.5%) were male; and 146 (61.9%) were primary care providers. In 2000, more physicians agreed that "caring for inpatients is an inefficient use of my time" (P<.001), and that "use of a hospitalist service improves quality of care" (P =.002). In 2000, more physicians disagreed that "use of a hospitalist service diminishes physician career satisfaction" (P<.001), and that "use of the hospitalist service adversely affects the physician-patient relationship" (P<.001). No differences were detected in responses to questions regarding patient satisfaction or overall career satisfaction. In multivariable models, older physicians were more likely to favor the hospitalist model; those with busier inpatient practices were more negative (P<.05 for each). Physician specialty or being a primary care provider was not associated with attitudes toward the hospitalist model. CONCLUSIONS: Following experience with a hospitalist system, physician attitude, including concerns regarding career satisfaction and relationships with patients, toward a voluntary hospitalist model improved. Future research should investigate whether the hospitalist model affects patient satisfaction and quality of care.

Adult↗

PubMed2003

Quality dimensions that most concern people with physical and sensory disabilities.

BACKGROUND: People with physical and sensory disabilities face important challenges in obtaining high-quality health care. We examined whether persons who are blind or have low vision, who are deaf or hard of hearing, or who have mobility impairments or manual dexterity problems are satisfied with the technical and interpersonal aspects of their care. METHODS: By using a 1996 nationally representative survey of 16 403 community-dwelling elderly and disabled Medicare beneficiaries, we identified persons with disabling conditions. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) controlled for demographic characteristics and managed care membership in predicting dissatisfaction with 12 dimensions of care. RESULTS: Of an estimated 33.58 million noninstitutionalized Medicare beneficiaries, 64.1% (an estimated 21.51 million) reported at least 1 potential disability and 29.5% (an estimated 9.89 million) reported more than 1 potential disability. Roughly 98% of people with and without disabilities believed their physicians were competent and well trained. But statistically significantly more people with disabilities reported dissatisfaction with care for 10 of the 12 quality dimensions. Persons reporting any major disability were more likely to be dissatisfied with physicians completely understanding their conditions (AOR, 2.4; 95% CI, 1.9-3.1), physicians completely discussing patients' health problems (AOR, 2.4; 95% CI, 1.9-2.9), physicians answering all patients' questions (AOR, 2.3; 95% CI, 1.7-3.1), and physicians often seeming hurried (AOR, 1.6; 95% CI, 1.4-1.9). CONCLUSIONS: Persons with disabilities generally reported positive views of their care, although they were significantly more likely to report poor communication and lack of thorough care. These findings held regardless of the disabling condition. Thoughtful systematic approaches are required to improve communication and to reduce time pressures that might compromise the health care experiences of people with disabilities.

Adolescent↗

PubMed2003

Length of stay in home care before and after the 1997 Balanced Budget Act.

CONTEXT: Prior to 1997, home health agencies (HHAs) were reimbursed on a fee-for-service basis and had incentives to provide more services. The 1997 Balanced Budget Act (BBA) reduced payments for home care services to help control Medicare spending. OBJECTIVE: To examine the length of stay in home care before and after the 1997 BBA. DESIGN AND SETTING: Cross-sectional study of home care patients in the 1996 and 1998 National Home and Hospice Care Surveys, which surveyed 1053 HHAs in 1996 and 1088 HHAs in 1998. PATIENTS: Nationally representative random sample of home care patients with Medicare coverage in 1996 (4127 patients) and 1998 (4051 patients). MAIN OUTCOME MEASURE: Length of stay in home care (based on the number of days a patient was enrolled in home care services). RESULTS: From 1996 to 1998, unadjusted median length of stay decreased by 16 days for all home care patients (60-44 days, P =.002). The decrease affected for-profit HHAs more than not-for-profit HHAs (111-55 days [51% decrease, P =.002] vs 46-36 days [22% decrease, P =.042]). In a Cox proportional hazards model of time to discharge from home care, post-BBA year (1998) was associated with a shorter length of stay in home care (adjusted hazard ratio [aHR] for home care discharge, 1.39 [95% confidence interval [CI], 1.19-1.61]), and for-profit status was associated with a longer length of stay in home care (aHR, 0.82 [95% CI, 0.71-0.94]) after adjusting for patient demographics, diagnoses, and functional status. CONCLUSION: After the 1997 BBA, length of stay in home care decreased among Medicare patients, particularly among those receiving care from for-profit HHAs.

Aged↗

PubMed2003

Hospice use among Medicare managed care and fee-for-service patients dying with cancer.

CONTEXT: For most patients aged 65 years or older with cancer, hospice services are uniformly covered by Medicare. Hospice care is believed to improve care for patients at the end of life. However, few patients use hospice and others enroll too late to maximize the benefits of hospice services. OBJECTIVES: Because type of insurance may affect use, we examined whether patients with Medicare managed care insurance enrolled in hospice earlier and had longer hospice stays than patients with Medicare fee-for-service (FFS) insurance. DESIGN AND SETTING: Retrospective analysis of the last year of life using the Linked Medicare-Tumor Registry Database in 1 of 9 Surveillance, Epidemiology, and End Results program coverage areas. PATIENTS: A total of 260 090 Medicare beneficiaries aged 66 years or older diagnosed with first primary lung (n = 62 117), colorectal (n = 57 260), prostate (n = 59 826), female breast (n = 37 609), bladder (n = 19 598), pancreatic (n = 11 378), gastric (n = 9599), or liver (n = 2703) cancer between January 1, 1973, and December 31, 1996, and who died between January 1, 1988, and December 31, 1998. MAIN OUTCOME MEASURES: Time from diagnosis to hospice entry and hospice length of stay for patients enrolled in FFS vs managed care plans after adjusting for patient demographics, tumor registry, year of hospice entry, and type and cancer stage. RESULTS: Of the 260 090 patients, most were men (59%), white (85%), and enrolled in FFS (89.7%). Only 54 937 patients (21.1%) received hospice care before death. Hospice use varied by type of primary cancer ranging from 31.8% of patients with pancreatic cancer to 15.6% with bladder cancer. Managed care patients were more likely to use hospice than FFS patients (32.4% vs 19.8%, P<.001). Among hospice patients, median (interquartile range) length of stay was longer for managed care vs FFS patients (32 days [11-82] vs 25 days [9-66], P<.001). After adjustment, managed care patients had higher rates of hospice enrollment (adjusted hazard ratio [HR], 1.38; 95% CI, 1.35-1.42) and had a longer length of stay (adjusted HR, 0.91; 95% CI, 0.88-0.94) vs FFS patients. Managed care patients were less likely to enroll in hospice within 7 days of their death (18.6% vs 22.6%, P<.001) and somewhat more likely to enroll in hospice more than 180 days before death (7.8% vs 6.1%, P<.001); the results for each of the 8 cancer diagnoses were similar. Hospice enrollment and length of stay among managed care vs FFS patients differed significantly by region. CONCLUSION: Medicare beneficiaries enrolled in managed care had consistently higher rates of hospice use and significantly longer hospice stays than those enrolled in FFS. Although these differences may reflect patient and family preferences, our findings raise the possibility that some managed care plans are more successful at facilitating or encouraging hospice use for patients dying with cancer.

Aged↗

PubMed2003

Screening for statin-related toxicity: the yield of transaminase and creatine kinase measurements in a primary care setting.

BACKGROUND: Recommendations for monitoring levels of transaminases (alanine aminotransferase and aspartate aminotransferase) and of creatine kinase (CK) in patients taking 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) vary and are not based on data from clinical practice. We performed a study to determine the yield of routine screening of aminotransferase and CK levels among patients taking statins. METHODS: We performed a retrospective review of a primary care practice's computerized medical record. A computerized search identified all patients with a statin on their medication list and gave their alanine aminotransferase, aspartate aminotransferase, and CK values for 1998. We reviewed the records of all patients for whom these values were significantly or moderately abnormal to determine the values' relationship to statin therapy and outcomes. RESULTS: During the year of the study, 1014 (85%) of the 1194 patients who had a statin on their medication list had at least 1 monitoring test performed. Of these 1014 patients, 10 (1.0%) had a significant elevation and 5 (0.5%) a moderate elevation of transaminase levels, but none of these abnormalities appeared to be related to statin use. Moreover, 6 (0.9%) patients had at least 1 significantly abnormal CK value but it did not appear to be attributable to a statin; and of the 14 (2.1%) patients who had a moderate CK elevation, it was potentially due to a statin in only 2. There were no documented adverse sequelae associated with these abnormal results. CONCLUSIONS: In this study of statin use in a primary care practice, routine monitoring revealed no cases of significantly or moderately abnormal transaminase values attributable to statins. No significantly abnormal and only 2 moderately abnormal CK values were potentially attributable to statin use. This study questions the usefulness of routine measurement of transaminase and CK levels in all patients taking statins.

Alanine Transaminase↗

PubMed2003

Barriers to hospice care among older patients dying with lung and colorectal cancer.

PURPOSE: To identify factors associated with hospice enrollment and length of stay in hospice among patients dying with lung or colorectal cancer. METHODS: We used the Linked Medicare-Tumor Registry Database to conduct a retrospective analysis of the last year of life among Medicare beneficiaries diagnosed with lung or colorectal cancer at age > or = 66 years between January 1, 1973, and December 31, 1996, in the Surveillance, Epidemiology, and End Results Program who died between January 1, 1988, and December 31, 1998. Our outcomes of interest were time from cancer diagnosis to hospice enrollment and length of stay in hospice care. We used Cox proportional hazards regression to adjust for demographic and clinical information. RESULTS: We studied elderly patients dying with lung cancer (n = 62,117) or colorectal cancer (n = 57,260). Overall, 27% of patients (n = 16,750) with lung cancer and 20% of patients (n = 11,332) with colorectal cancer received hospice care before death. Median length of stay for hospice patients with lung and colorectal cancer was 25 and 28 days, respectively. Overall, 20% of patients entered hospice within 1 week of death, whereas 6% entered more than 6 months before death. Factors associated with later hospice enrollment include being male; being of nonwhite, nonblack race; having fee-for-service insurance; and residing in a rural community. Many of these factors also were associated with shorter stays in hospice. CONCLUSION: Although use of hospice care has increased dramatically over time, specific patient groups, including men, patients residing in rural communities, and patients with fee-for-service insurance continue to experience delays in hospice enrollment.

Aged↗

PubMed2003

Patterns and perceptions of care for treatment of back and neck pain: results of a national survey.

STUDY DESIGN: We conducted a nationally representative random household telephone survey to assess therapies used to treat back or neck pain. OBJECTIVES: The main outcome was complementary therapies used in the last year to treat back or neck pain. SUMMARY OF BACKGROUND DATA: Back pain and neck pain are common medical conditions that cause substantial morbidity. Despite the presumed importance of complementary therapies for these conditions, studies of care for back and neck pain have not gathered information about the use of complementary therapies. METHODS: Our nationally representative survey sampled 2055 adults. The survey gathered detailed information about medical conditions, conventional and complementary therapies used to treat those conditions, and the perceived helpfulness of those therapies. RESULTS: We found that of those reporting back or neck pain in the last 12 months, 37% had seen a conventional provider and 54% had used complementary therapies to treat their condition. Chiropractic, massage, and relaxation techniques were the most commonly used complementary treatments for back or neck pain (20%, 14%, and 12%, respectively, of those with back or neck pain). Chiropractic, massage, and relaxation techniques were rated as "very helpful" for back or neck pain among users (61%, 65%, and 43%, respectively), whereas conventional providers were rated as "very helpful" by 27% of users. We estimate that nearly one-third of all complementary provider visits in 1997 (203 million of 629 million) were made specifically for the treatment of back or neck pain. CONCLUSIONS: Chiropractic, massage, relaxation techniques, and other complementary methods all play an important role in the care of patients with back or neck pain. Treatment for back and neck pain was responsible for a large proportion of all complementary provider visits made in 1997. The frequent use and perceived helpfulness of commonly used complementary methods for these conditions warrant further investigation.

Adolescent↗

PubMed2003

Older Asian Americans and Pacific Islanders dying of cancer use hospice less frequently than older white patients.

PURPOSE: Cancer is the leading cause of death among Asian Americans, yet little is known about their use of hospice care. We examined hospice use by Asian patients compared with white patients, and assessed whether utilization differs among those born in the United States or abroad. METHODS: We studied Asian and white Medicare beneficiaries registered in the Surveillance, Epidemiology, and End Results (SEER) Program who died of primary lung, colorectal, prostate, breast, gastric, or liver cancer between 1988 and 1998. We used logistic regression to determine the effects of race/ethnicity and birthplace on hospice use, adjusting for demographic characteristics, managed care insurance, year of diagnosis, tumor stage at diagnosis, and tumor registry. RESULTS: Of the 184,081 patients, 5% (n = 8614) were Asian Americans, of whom 45% (n = 3847) were foreign born. Compared with whites, Asian Americans were more likely to be male, married, and enrolled in managed care. Compared with U.S.-born Asian Americans, foreign-born Asian Americans were more likely to reside in low-income areas. After adjustment, patients who were Asian American (odds ratio [OR] = 0.67; 95% confidence interval [CI]: 0.62 to 0.73) and born abroad (OR = 0.90; 95% CI: 0.86 to 0.94) were less likely to use hospice care than were white patients. These results were consistent across the six cancer diagnoses that were examined. CONCLUSION: Older Asian Americans dying of cancer, especially those who are born abroad, are less likely than white patients to use hospice care at the end of life. Additional research is needed to understand the reasons for these differences and to eliminate potential barriers to hospice care.

Age Factors↗

PubMed2003

Linguistic and cultural barriers to care.

CONTEXT: Primarily because of immigration, Asian Americans are one of the fastest growing and most ethnically diverse minority groups in the United States. However, little is known about their perspectives on health care quality. OBJECTIVE: To examine factors contributing to quality of care from the perspective of Chinese- and Vietnamese-American patients with limited English language skills. DESIGN: Qualitative study using focus groups and content analysis to determine domains of quality of care. SETTING: Four community health centers in Massachusetts. PARTICIPANTS: A total of 122 Chinese- and Vietnamese-American patients were interviewed in focus groups by bilingual interviewers using a standardized, translated moderator guide. MAIN OUTCOME MEASURES: Domains of quality of care mentioned by patients in verbatim transcripts. RESULTS: In addition to dimensions of health care quality commonly expressed by Caucasian, English-speaking patients in the United States, Chinese- and Vietnamese-American patients with limited English proficiency wanted to discuss the use of non-Western medical practices with their providers, but encountered significant barriers. They viewed providers' knowledge, inquiry, and nonjudgmental acceptance of traditional Asian medical beliefs and practices as part of quality care. Patients also considered the quality of interpreter services to be very important. They preferred using professional interpreters rather than family members, and preferred gender-concordant translators. Furthermore, they expressed the need for help in navigating health care systems and obtaining support services. CONCLUSIONS: Cultural and linguistically appropriate health care services may lead to improved health care quality for Asian-American patients who have limited English language skills. Important aspects of quality include providers' respect for traditional health beliefs and practices, access to professional interpreters, and assistance in obtaining social services.

Asian↗

PubMed2003

Hospitalization of hospice patients with cancer.

OBJECTIVES: To identify factors associated with hospitalization of elderly hospice patients with cancer and to describe their hospital experiences. DESIGN: Retrospective analysis of the last year of life. SETTING: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database. PARTICIPANTS: Medicare beneficiaries dying of lung or colorectal cancer between 1988 and 1998 who enrolled in hospice. MEASUREMENTS: Hospitalization after hospice entry. For hospitalized patients, we describe admission diagnoses, aggressiveness of care, and in-hospital death. RESULTS: Of the 23608 patients, 1423 (6.0%) were hospitalized after hospice enrollment. Hospitalization declined over time by 7.0% per year of hospice enrollment. Factors associated with higher hospitalization rates were younger age, male gender, black race/ethnicity, local cancer stage at diagnosis, and hospice enrollment within 4 months of cancer diagnosis. The most common reasons for hospital admission were lung cancer, metastatic disease, bone fracture, pneumonia, and volume depletion. Of the 1423 patients hospitalized, 34.6% received aggressive care and 35.8% died in the hospital. CONCLUSION: The rates of hospitalization for elderly hospice patients with lung or colorectal cancer appear to be declining. However, patients who are hospitalized undergo aggressive care and often die in the hospital rather than at home. This aggressive care may be consistent with changes in patients' care preferences, but could also reflect the current culture of acute care hospitals, which focuses on curative treatment and is ill-equipped to provide palliative care.

Aged↗