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PubMedDate not supplied

Use of hospital-based ambulatory care in New York City's Health Manpower Shortage Areas.

The development of a comprehensive data base for hospital-based ambulatory care has made possible the accurate determination of each community's use of hospitals in New York City and permits a reliable estimation of all ambulatory care received by residents of Health Manpower Shortage Areas (HMSAs). In spite of the city's abundant supply of private practitioners and widespread Medicaid coverage, residents of HMSAs in New York City are heavily dependent on hospital-based ambulatory care. Contrary to commonly held notions, however, HMSA residents do not appear to overuse hospital-based ambulatory care. Rather, that use appears to be quite modest, given their poorer health status.

Ambulatory Care Facilities↗
PubMed1986

The impact of the acquired immunodeficiency syndrome on patterns of premature death in New York City.

This report examines the impact of acquired immunodeficiency syndrome (AIDS) on patterns of mortality among persons aged 15 to 64 years in New York City. The New York City AIDS surveillance registry was matched to the New York City vital statistics registry to identify deaths caused by AIDS. In 1984, the AIDS mortality rate per 100,000 persons aged 15 to 64 years was 42.2 for males and 5.3 for females. Analyzed by five-year age groups, AIDS was among the five leading causes of death for males aged 25 to 54 years, and the leading cause of death for males aged 30 to 39 years. For females, AIDS was the fourth leading cause of death for women aged 25 to 29 years, and the second leading cause for women aged 30 to 34 years. Almost 10% of the years of potential life lost to males aged 15 to 64 years was due to AIDS, and for females, 3.6%. For both men and women in the highest-risk age group, 20 to 44 years, blacks and Hispanics had higher mortality rates than Asians or whites. The higher mortality in blacks and Hispanics is believed to be related to a higher prevalence of drug abuse in these populations and not to ethnicity per se. These findings document the enormous increases in premature mortality attributable to AIDS.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

The status of tuberculosis control in New York City.

Problems in tuberculosis control still exist in New York City. They range from an increase in the incidence of the disease to the discovery of new cases in children under 5 years of age. Ninety-three percent (1,395) of the cases reported in 1980 were verified by cultures positive for tuberculosis. The rest of the cases in the 1980 tuberculosis disease count were verified by histology or a physician's recommendation for treatment with two or more antituberculosis drugs. Of the tuberculosis at extrapulmonary sites, pleural meningeal and miliary tuberculosis, as well as genitourinary tuberculosis, ranked high in incidence in 1980. New tuberculosis cases occurred in all age groups, but the 37 cases in the age group 0-4 years is alarming and indicates a high rate of transmission of tuberculosis from parents to children. Performance indicators of the Centers for Disease Control show that in terms of drug continuity, completion of treatment, and bacteriological conversions to negative, a great deal needs to be done in New York City. The tuberculosis mortality rate for the city has been showing a steady decline over the years; it was 1.8 per 100,000 population in 1980.

Adolescent↗
PubMed1995

New York City physicians serving high volumes of Medicaid children: who are they and how do they practice?

This study examined, in 1993, the characteristics and practices of New York City physicians who submit large numbers of Medicaid claims for children. Of our sample of 33 physicians, more than 90% were educated outside the United States; fewer than half were board certified or had hospital staff appointments. These physicians saw a clientele who were 98% Medicaid; most visits (82%) were at a time of acute illness. With the rapid advent of mandatory, Medicaid managed care in New York City, and with the large estimated gap in primary care capacity in the inner city, policy questions arise as to whether these physicians should be integrated into managed care plans. If they are not, the question becomes: how will they be replaced?

Adolescent↗
PubMedDate not supplied

Sex, drugs, and syringe exchange in New York City: women's experiences.

The sex and drug human immunodeficiency virus (HIV) risk factors of drug-injecting women participating in New York City syringe exchange programs were studied and racial/ethnic differences examined. African-American women reported injecting least frequently and had lower rates of injecting with borrowed or used syringes. Women attending syringe exchange reported high levels of sexual risk behavior, and syringe exchange provides an opportunity for a sexual risk reduction intervention. Women were more likely to "always" use condoms with causal partners than with primary partners. About 60% of the women engaging in commercial sex work reported "always" using condoms. Three independent predictors for consistent condom use with primary partners were: knowing one's HIV status, any risky injection during the past 30 days, and being African-American, compared with white or Latina. The profile of African-American women attending syringe exchange in New York City suggests a higher level of stabilization than is found in the other groups of women. White women appear to be more socially isolated and to engage in higher risk behaviors. Although women attending New York City syringe exchange programs have significantly reduced risky drug injection, consistent with other studies, sexual risk behavior has remained at a high level. Syringe exchange and drug treatment programs have a great opportunity to target drug-injecting women for sexual risk reduction interventions.

Adult↗
PubMed1995

Increasing HIV-1 seroprevalence associated with genital ulcer disease, New York City, 1990-1992.

OBJECTIVE: To measure HIV seroprevalence trends associated with sexually transmitted diseases (STD) causing ulcerative lesions [genital ulcer disease (GUD)], such as syphilis, chancroid and genital herpes, in New York City between 1990 and 1992. DESIGN: Unlinked HIV-1 serosurvey using remnant serum drawn originally for routine syphilis screening. SETTING AND PATIENTS: Consecutive sample of patients presenting to New York City Department of Health STD clinics for STD examination (n = 41,678). MAIN OUTCOME MEASURE: Serologic evidence of antibody to HIV-1. RESULTS: Although overall HIV seroprevalence and GUD incidence declined between 1990 and 1992, seroprevalence in patients with GUD increased from 10 to 16%. In contrast, seroprevalence in patients with non-ulcerative STD decreased. The most dramatic changes in seroprevalence associated with GUD occurred in patients using crack cocaine and injecting drugs. CONCLUSIONS: Despite declining HIV seroprevalence and GUD incidence, the association between GUD and HIV infection has strengthened over time in New York City STD clinics. Longitudinal incidence studies are needed to elucidate the biological, behavioral and temporal associations between GUD and HIV. Timely diagnosis and treatment of acute STD and more intensive risk reduction strategies at the clinics and associated testing sites, with a particular focus on GUD patients, are indicated.

Female↗
PubMed1994

Nurse practitioners, certified nurse midwives, and nurse anesthetists: changing care in acute care hospitals in New York City.

To respond to the shrinking pool of primary care physicians and to demands from managed care programs for cost containment, hospitals in New York City have increased their use of nurse practitioners, certified nurse midwives, and nurse anesthetists, creating an increased demand for these personnel. We report here on a survey of hospitals and schools of nursing in New York City and present findings on (a) current use of, and projected demand for nurse practitioners (NPs), certified nurse midwives (midwives) and nurse anesthetists (anesthetists) in hospitals in New York City; (b) the practice patterns of NPs, midwives, and anesthetists currently employed in hospitals; and (c) current and projected enrollment and curriculum in NP, midwifery, and anesthetist education programs in the New York metropolitan area.

Adult↗
PubMed1994

An estimate of the prevalence of asthma and wheezing among inner-city children.

OBJECTIVE: To estimate the prevalence of asthma and wheezing unassociated with a diagnosis of asthma among inner-city children. DESIGN: Cross-sectional survey of a sample of Bronx households. METHODS: Random digit dialing telephone survey using parental report. SETTING: Bronx County, NY. PARTICIPANTS: 662 self-designated heads-of-household who reported for all children 0 through 17 years of age living in their households. MEASUREMENTS: Questions from the Child Health Supplement to the 1988 National Health Interview Survey and the International Union Against Tuberculosis and Lung Disease Bronchial Symptoms Questionnaire were used to estimate the prevalence of asthma and wheezing-related illness. RESULTS: Information was gathered on 1285 children. Of this sample, 184 (14.3%) were reported to have ever had asthma (cumulative prevalence) and 111 (8.6%) were reported to have asthma in the last 12 months (period prevalence). The asthma period prevalence rate among Bronx children was twice the United States rate (4.3%). Among children 0 through 11 years of age, the prevalence rate was similar for boys and girls, although among children 12 through 17 years of age, asthma was significantly more prevalent among boys. Fifty-four children (4.2%) were reported to have had wheezing in the past 12 months unassociated with a diagnosis of asthma (wheeze only). The cumulative, but not the period, prevalence rate of asthma differed significantly by income and race/ethnicity. The cumulative prevalence was significantly higher among Hispanics and children from the lowest income families. The prevalence of wheeze only (no reported history of asthma) was higher among whites (6.4%) and blacks (5.8%) than Hispanics (2.9%) (P < .1). The reported number of wheezing attacks and the average number of nights per week that sleep was disturbed by wheezing during the past year were similar for those with asthma and those with wheeze only, although severe attacks (wheezing severe enough to limit speech) were significantly more likely among those reported to have asthma (P < .001). The total asthma prevalence (period prevalence of asthma plus wheeze only) was 12.8% and was quite consistent across subgroups. CONCLUSIONS: These data suggest that the prevalence of asthma among inner-city children may be substantially higher than the rates for this group estimated from national survey data. Some proportion of the wheeze only group may represent undiagnosed, and thereby undertreated, asthma. Public health efforts directed at reducing asthma morbidity and mortality need to address the possibility that asthma prevalence is higher within inner cities and that a large number of children with asthma may be inadequately diagnosed and treated.

Adolescent↗
PubMedDate not supplied

Tuberculosis surveillance using death certificate data, New York City, 1992.

OBJECTIVE: To determine the accuracy and frequency of reporting tuberculosis as either the contributing or underlying cause of death on death certificates in New York City during 1992. METHODS: Death certificates from 1992 that listed tuberculosis were matched with the New York City tuberculosis registry. For those persons who had tuberculosis listed as a cause of death, but who were not listed in the registry, medical records were reviewed. The frequency of reporting tuberculosis on death certificates in patients who died with active tuberculosis was evaluated in the second part of this study. Death certificates of patients with active tuberculosis (persons who died within six months of starting anti-tuberculosis medications) in 1992 were reviewed. RESULTS: Tuberculosis was listed on 635 death certificates; 377 (59%) were confirmed cases based on registry data. Reviews of medical records were possible for 230 (89%) of the remaining 258 patients and confirmed only two additional tuberculosis cases. Of 310 persons who died with active tuberculosis in 1992 (second part of the study), only 104 (34%) had tuberculosis listed on their death certificates. CONCLUSIONS: In New York City, a diagnosis of tuberculosis on death certificates is an inaccurate measure of tuberculosis burden.

Adolescent↗
PubMedDate not supplied

Stabilizing the HIV/AIDS workforce: lessons from the New York City experience.

The Ryan White Title I Personnel Needs Study described here is an evaluation of the human resource needs of HIV/AIDS service agencies in New York City. The research presented here was conducted in collaboration with researchers from the Medical and Health Research Association and the New York City Department of Health and the Planning and Evaluation Committee of the New York City HIV Health and Human Services Planning Council. The assessment is divided into two components. The first component is a survey of 100 key informants from HIV/ AIDS service agencies. The second component is a detailed staffing survey of 70 personnel directors of HIV/AIDS service agencies. HIV/AIDS service directors perceived staff recruitment as a more difficult process than staff retention, regardless of agency type. Vacancy rates at the surveyed agencies varied by professional category; they were especially high in the category of nurse practitioners (13%) and outreach/education workers (15%). Agencies stressed that incentives that would positively affect recruitment and retention should be tailored to address the concerns of varied health care and social service professionals. In addition, agencies were not routinely able to provide some incentives deemed effective such as higher salaries, housing subsidies, and smaller caseloads. To reduce recruitment and retention problems, agency informants recommended a variety of incentive programs including malpractice insurance for physicians, flexible hours for full-time employees (including case managers, nurses, physician's assistants), smaller caseloads, and a decrease in the proportion of staff time devoted to direct client contact. Overall health care trends including truncated federal budgets, state Medicaid cutbacks, and the rapid conversion to managed care all affect the quality of patient care and of the work setting for health care and social service providers serving persons with AIDS. Medical Subject Headings (MeSH): AIDS, health personnel, employment supported, employee workload, staff attitude.

Acquired Immunodeficiency Syndrome↗
PubMed1997

A city-wide outbreak of a multiple-drug-resistant strain of Mycobacterium tuberculosis in New York.

SETTING: Incident patients with active tuberculosis (TB) resistant to two or more drugs in New York City hospitals in 1992. OBJECTIVE: To examine the New York-wide distribution of Public Health Research Institute (PHRI) strain W of Mycobacterium tuberculosis, an extremely drug-resistant strain identified by a 17-band Southern hybridization pattern using IS6110, during the peak tuberculosis year of 1992. We also compared strain W with other strains frequently observed in New York. DESIGN: Blinded retrospective study of stored M. tuberculosis cultures by restriction fragment length polymorphism (RFLP) DNA fingerprinting, and chart review. RESULTS: We found 112 cultures with the strain W fingerprint and 8 variants in 21 hospitals among incident patients hospitalized in 1992. Almost all isolates were resistant to four first-line drugs and kanamycin. This single strain made up at least 22% of New York City multiple-drug-resistant (MDR) TB in 1992, far more than any other strain. Almost all W-strain cases were acquired immune deficiency syndrome (AIDS) patients. The cluster is the most drug-resistant cluster identified in New York and the largest IS6110 fingerprint cluster identified anywhere to date. CONCLUSION: Because recommended four-drug therapy will not sterilise this very resistant strain, there was a city-wide nosocomial outbreak of W-strain TB in the early 1990s among New York AIDS patients. Other frequently seen strains were either also very resistant, or, surprisingly, pansusceptible. Individual MDR strains can be spread widely in situations where AIDS and TB are both common.

Adult↗
PubMed1997

Tuberculosis among foreign-born persons in New York City, 1992-1994: implications for tuberculosis control.

OBJECTIVE: To study the pattern of transmission of tuberculosis (TB) among foreign-born persons living in New York City. DESIGN: A retrospective multicenter study comparing 158 foreign-born patients to 231 US-born patients diagnosed with TB between 1992 and 1994. The patients were stratified according to their Mycobacterium tuberculosis isolate DNA fingerprint patterns. RESULTS: Nineteen (16%) of 122 isolates from foreign-born TB patients and 75 (42%) of 180 isolates from US-born TB patients had DNA fingerprint patterns (cluster patterns) indicative of recent exogenous transmission (P < 0.001). All cluster pattern strains from foreign-born cases were identical to those found among US-born patients. The likelihood of infection with a cluster pattern strain among foreign-born persons increased with duration of residence in the US, and was significantly associated with being homeless (P < 0.05), or having multidrug-resistant TB (P = 0.00072). CONCLUSION: Although most (84%) cases of TB among foreign-born persons in New York City appear to result from reactivation of infections they acquired abroad, the ones who acquire new infections become infected with strains that are already circulating among the US-born TB patients in New York City, and they have risk factors similar to those faced by US-born tuberculosis patients.

Adult↗
PubMedDate not supplied

Use of the intrauterine device by inner-city women.

OBJECTIVE: To examine the use, effectiveness, acceptability, and continuation rates of the copper T 380 A intrauterine device (IUD) among women attending an inner-city family planning clinic. DESIGN: A 1-year prospective cohort study. SETTING: The family planning clinic of Grady Memorial Hospital, which serves the inner-city indigent population of Fulton and Dekalb counties in metropolitan Atlanta, Ga. PARTICIPANTS: A total of 115 women with 1 or more live births who were in a mutually monogamous relationship for the previous year had the copper T 380 A IUD inserted between December 20, 1990, and June 28, 1991. MAIN OUTCOME MEASURES: Follow-up, consisting of history and a pelvic examination, was done 2, 6, and 12 months after IUD insertion to determine the status of the IUD and to detect any complications related to its use. At the end of the study, the continuation rates, reasons for removal, and complications related to IUD use were assessed. RESULTS: Thirty-seven women were unavailable for follow-up. Eight of those were seen in other clinics at Grady Memorial Hospital, but no mention was made of their IUD status. Fifty-six of the remaining 78 women were known to continue IUD use without any complications at the end of the 12 months. Among the 22 women known to have the IUD removed, 8 women cited no problems. Pelvic pain, menometrorrhagia, desire for permanent sterilization, and expulsion of the device were mentioned as reasons for other IUD removals. Pelvic inflammatory disease was not documented in any of the patients during the year of follow-up. CONCLUSION: With proper screening and counseling, the IUD may be used successfully in selected patients in inner-city family planning clinics.

Adolescent↗
PubMed2003

The long-term effects of a self-management program for inner-city primary care patients with acute low back pain.

BACKGROUND: We evaluated the effect of a self-management program for low-income primary care patients with acute low back pain (ALBP) from inner-city neighborhood health centers. METHODS: We conducted a randomized controlled trial of a self-management program compared with usual care at university-affiliated neighborhood health centers and an emergency department of an inner-city public teaching hospital. We enrolled 211 patients who visited a physician for ALBP (<90 days' duration). The self-management program consisted of 3 group sessions and telephone follow-up that focused on understanding back pain, increasing physical activity, and dealing with fears and frustrations. RESULTS: At baseline, 4 months, and 12 months, blinded interviewers assessed back pain physical function (Roland Disability Questionnaire), health status (Arthritis Impact Measurement Scales), self-efficacy, and time spent in physical activity. Compared with patients receiving usual care, intervention patients reported significantly better scores on the Roland Disability Questionnaire (P =.009), mental functioning (P =.009), self-efficacy to manage ALBP (P =.03), time spent in physical activity (P =.047), and reduced fears of movement/reinjury (P =.005) after 12 months. CONCLUSION: A self-management program can improve and maintain functional status, mental functioning, and self-efficacy to manage future symptoms for 1 year among primary care patients with ALBP living in the urban, inner city.

Adult↗
PubMed1984

Diagnosis-related groups analysis of medical care in four American cities.

The introduction of diagnosis-related groups (DRGs) into American medical care is having a considerable impact on hospital finance and utilization. Patterns of patient care for individual physicians will also be assessable with this system. We evaluated a one-year sample of data on hospital admissions for ear, nose, and throat disorders in four comparable American cities for length of stay variations. The trends from city to city included a wide variation in rates of admission per population of 100,000, especially in the major head and neck surgery category. Patterns of disease, specifically with regard to dysequilibrium and childhood salivary glands, may be a potentially unknown problem for the communities involved. Even though the present DRG system may be an oversimplified method of describing medical care, it does provide useful information for otolaryngologists-head and neck surgeons.

Costs and Cost Analysis↗
PubMed1998

Inner-city achievers: who are they?

OBJECTIVE: To define characteristics that differentiate inner-city children with Average or above-Average Full Scale IQ scores (> or =90) from those with below-Average scores (<90). DESIGN: As part of a prospective study of children with and without in utero cocaine exposure tested at age 4 years on the Wechsler Preschool and Primary Scales of Intelligence-Revised, we found that, taken together, only 32 (21%) scored at or above 90 whereas 118 (79%) scored below 90. The groups (IQ> or =90 and IQ<90) were compared on prenatal, natal, and postnatal factors. SETTING: A study center in an inner-city hospital. PARTICIPANTS: One hundred-fifty children of low socioeconomic status, 34 weeks' gestational age or older, and nonasphyxiated at birth, who had intelligence testing at age 4 years; 150 caregivers (biological and foster). MAIN OUTCOME MEASURES: Association of Full Scale IQ with prenatal, natal, and postnatal characteristics (including caregiver-child interaction measured by the Parent Caregiver Involvement Scale [PCIS], and home environment measured by the Home Observation for Measurement of the Environment [HOME]). RESULTS: The group of children with IQs at or above 90 (n = 32) did not differ from the group with IQs below 90 (n = 118) in prenatal or natal characteristics (all P> or =.18) or proportion in foster care, attendance at day care or Head Start, continued caregiver cocaine use, or parental IQ. Children with IQs at or above 90 had more developmentally appropriate interaction by caregivers (P=.043) and higher scores on 6 of 8 subscales and Total HOME (P< or =.05) than the group of children with IQs below 90. CONCLUSIONS: Two postnatal factors, home environment and caregiver-child interaction, were associated with Full Scale IQ scores at or above 90 whereas prenatal and natal factors were not. These potentially malleable postnatal factors can be targeted for change to improve cognitive outcome of inner-city children.

Achievement↗
PubMed1998

Reported difficulties in access to quality care for children with asthma in the inner city.

OBJECTIVE: To characterize perceived access and barriers to quality health care for asthma among the caregivers of children in the inner city. DESIGN: Multicenter, cross-sectional survey. SETTING: Eight sites in 7 major metropolitan US inner cities. PARTICIPANTS: A systematic sample of children with asthma, aged 4 to 9 years, and their caregivers who resided in census tracts in which at least 30% of the households were below the 1990 federal poverty guidelines, recruited from 25 primary care clinics and 13 emergency departments (EDs) from November 1, 1992, through October 31, 1993. RESULTS: Of the 1528 children enrolled, 1376 had physician-diagnosed asthma and form the basis of this report. This group was further divided into 284 children (20.6%) who met all recruitment criteria for severe asthma and 207 (15.0%) with mild asthma who met none. Of parents in the total sample, 95.6% reported a usual place for short-term asthma care for their child; 75.4% used the ED. Children with severe asthma were significantly more likely to use the ED than those with mild asthma (84.3% vs 63.0%; P<.01). A usual place for follow-up asthma care was reported by 96.7% of subjects. There were no differences in access or type of facility used by asthma severity. More than half the study group reported difficulty in accessing care for acute asthma attacks and for follow-up care with no differences by asthma severity. Among those with severe asthma, 47.5% used inhaled steroids or cromolyn, 52.8% used a spacer device if they had been prescribed a metered dose inhaler, and 21.2% of children older than 6 years were prescribed a peak flowmeter. Patients with mild asthma were significantly less likely to report use of all 3 items (steroids or cromolyn, 1.4%; spacer device, 15.4%; and peak flowmeter, 3.1%, respectively; P<.01). CONCLUSION: Although access to asthma care among children in US inner cities appears adequate as determined by the traditional measure of reporting a regular source of care, barriers are frequently reported, as are deficiencies in the quality of medical care.

Anti-Asthmatic Agents↗
PubMed1999

Depot medroxyprogesterone acetate use in inner-city, minority adolescents: continuation rates and characteristics of long-term users.

OBJECTIVE: To identify continuation rates of depot medroxyprogesterone acetate (Depo-Provera) and characteristics of long-term users in a population of inner-city, minority adolescents with high pregnancy rates. DESIGN: Retrospective medical record review. SETTING: An inner-city adolescent clinic and an adolescent pregnancy program. METHODS: A review of the medical records of 250 females aged 13 to 20 years (mean +/- SD, 16.8 +/- 1.1 years), 62.9% Hispanic and 34.2% African American, receiving a first depot medroxyprogesterone acetate injection for contraception between August 1993 and June 1996 was conducted using a standardized form. The mean +/- SD age at menarche of the subjects was 11.6 +/- 1.4 years, and the mean +/- SD age at first intercourse was 14.1 +/- 1.3 years; the mean number of lifetime sex partners was 2.4. Of the subjects, 73.6% had used condoms, 32.0% used oral contraceptives, and none used implants. Of the 201 subjects for whom there were data in the medical records regarding prior fertility, 172 (85.6%) had been pregnant, and 145 (72.1%) had a child. Life table analysis was used to measure depot medroxyprogesterone acetate continuation rates and to compare subgroups of adolescents. RESULTS: Depot medroxyprogesterone acetate continuation rates were found to be 70.3% at 6 months, 48.3% at 9 months, 31.5% at 12 months, and 12.8% at 24 months. The most common reason for depot medroxyprogesterone acetate discontinuation was missed appointments (41.7%). Subjects were followed up for a mean +/- SD of 1.3 +/- 0.7 years after discontinuation of depot medroxyprogesterone acetate use; 46.7% became pregnant. Among those 156 adolescents who discontinued depotmedroxyprogesterone acetate use, 40.0% restarted the method at some later time. Continuation of depot medroxyprogesterone acetate use was more likely if age at first intercourse was younger than 13 years (P = .04). Continuation rates were not related to age, ethnicity, age at menarche, number of sex partners, use of other contraceptives, prior pregnancy, or having a child. CONCLUSIONS: In this study, just less than one third of the adolescents continued depot medroxyprogesterone acetate use for 1 year or longer. This suggests that depot medroxyprogesterone acetate does not function as a long-term method for most inner-city adolescents. The only characteristic that was associated with successful continuation of depot medroxyprogesterone acetate use was young age at first intercourse, implying that experience may be the main determinant of continuation.

Adolescent↗