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The update also summarizes recent journal articles and other research developments in the field and features a data slide from a relevant Kaiser Family Foundation publication. 1. In Maryland, A Prescription for Better Health Care
9. Black Health Care Coalition Advocates for Health Choices DISPARITIES IN RESEARCH 16. Trends in Melanoma Mortality Among Non-Hispanic Whites by Educational Attainment, 1993 – 2007 17. Lower Socioeconomic Status and Disability Among US Adults With Chronic Kidney Disease, 1999 – 2008 18. Hispanic Lesbians and Bisexual Women at Heightened Risk or Health Disparities 20. Medical Expenditures Among Immigrant and Nonimmigrant Groups in the United States 23. Children With Cerebral Palsy: Racial Disparities in Functional Limitations 24. Disability Among Lesbian, Gay, and Bisexual Adults: Disparities in Prevalence and Risk DISPARITIES DATA SPOTLIGHT DISPARITIES IN THE NEWS 1. In Maryland, A Prescription for Better Health Care A recent article in the Washington Post discussed some of the geographic health disparities that exist in Maryland and what Lt. Gov. Anthony G. Brown and others are doing to improve the situation. Areas with a high population of people of color are more likely to experience higher rates of chronic disease, low-birthweight babies and limited access to care. One such area is Prince George County, Maryland, which includes a high population of blacks, in addition to high rates of asthma, HIV infection, diabetes, and a limited number of primary care medical facilities according to the article. Furthermore, a 2007 Rand report estimated that 80,000 adults in Prince George County, MD were uninsured. This rate was more than double the rate in Howard County, and nearly 33 percent higher than the rate in Montgomery County. The article noted out that most uninsured residents wait until the last minute to seek care, and the care they do receive tends to be more expensive. Lt. Gov. Anthony G. Brown unveiled a proposal to reduce health disparities within the state. This proposal was created by a group headed by E. Albert Reece, dean of the University of Maryland medical school. The group recommended that the Maryland legislatures create health-care zones, which would give local governments the authority to office incentives to providers to encouragement them to practice in underserved areas. The idea is similar to economic-enterprise zones. “There is, I think, both a moral imperative and, quite frankly, an economic imperative and a case to be made that health disparities need to be eliminated,” Brown said. Brown hopes to roll out a pilot program in the fall, which he hopes will bring down the cost associated with health disparities in the state. The pilot program is also expected to be funded through governor’s budget when it is released according to the article (Spivack, 1/17). 2. More Docs No Help for Racial Colonoscopy Gap A recent article in Medpage Today reported on a study that examined the relationship between the physician supply and disparities in colon cancer screening among Medicare beneficiaries in Texas, and surprisingly found greater disparities in areas with more physicians. Prior research has demonstrated persistent racial and ethnic disparities in colorectal cancer screening rates. The authors of this study hypothesized that disparities would be smaller in areas where providers are plentiful. Using claims data from almost 975,000 Medicare beneficiaries in Texas who were white, black, or Hispanic and between the ages 66 to 79 years in 2007, the researchers compared colonoscopy rates by provider availability. Physician availability was measured using the number of doctors per 10,000 people who are 65 or older in a given Hospital Service Area. After adjusting for age, sex, comorbidities, income, and risk factors for colon cancer, the authors found blacks and Hispanics were less likely to have a colonoscopy than whites. Even after controlling for those who live in areas with the highest odds of receiving a colorectal screening, racial and ethnic disparities remained. The results indicate that the odds of receiving a colonoscopy for people of color increased when physicians who perform colorectal screenings were more available. The authors noted that “Our data imply that increasing colonoscopist capacity alone may not improve colonoscopy use and may be associated with increased racial/ethnic disparities” (Ullman, 1/17). 3. Programs Improve Diabetes Care in Low-Income Areas According to a recent article published by MedPage Today, two new initiatives have been successful in improving diabetes management in underserved populations. Previous research indicates that many factors contribute to racial and ethnic disparities in diabetes and many efforts are underway to bridge the gap. In one study, Dr. Peter Huckfeldt investigated the impact of diabetes management interventions in Los Angeles, CA. The study found health improvements for patients enrolled in community interventions featuring targeted diabetes care as well as integrated primary care. In the second study, Dr. Monica Peek also found promising results for a diabetes management program in Chicago. This program aimed to reduce disparities through community partnerships as well as culturally competent patient education and provider trainings. Both studies concluded that the health care safety net can be strengthened to better address the needs of high risk diabetes patients (Neale, 1/13). 4. Asian-Americans More Apt to Die in Hospital After Heart Attacks Health Day reported on a five-year study that found improvement in the number of heart attack mortalities among Asian-Americans; however, they were still more likely than whites to die in a hospital. The study included over 107,000 Asian-American and white heart attack patients from 2003 to 2008. The authors explored what certain measures of care, (e.g. whether a patient received an aspirin or ACE inhibitors, counseling on how to quit smoking, were made available to a patient after discharge. The results found Asian-Americans were less likely to receive such care and twice as likely to die in a hospital after a heart attack. “Health disparities are a serious public health concern in the United States and we’ve seen that different racial and ethnic groups often receive unequal treatment for the same diagnosis,” said Dr. Feng Qian, a research assistant professor in the anesthesiology department at the University of Rochester Medical Center in New York. Possible factors for the disparity included Asian-Americans being much older, and other health issues such as diabetes, hypertension, and smoking. The researchers did find as the quality of care improved, the health disparity decreased. “This improved care is more significant and sustainable the longer hospitals participate in the program,” said Qian. These results prompted the lead author, Dr. Qian, to say “Future studies should look more specifically at differences in care among racial subgroups as well as at more long-term outcomes,” (Dallas, 1/10). 5. Lower Risk of Death Linked With Access to Key Attributes of Primary Care, UC Davis Study Shows In a recent article published by Health Canal, new research has linked three primary care characteristics with reduced morality risk. Previous studies have found reduced mortality risk for individuals living in regions with high concentrations of primary care practitioners. In a new study, Anthony Jerant sought to determine if three primary care practice characteristics were associated with increased life expectancy. Using data from the Medical Expenditure Panel Surveys, the study analyzed patient descriptions of their main doctor’s office. The researchers found that respondents whose primary doctor’s office provided: patient-centered care, comprehensive health care services, and extended office hours fared the best over a six year period. The study concluded that these three characteristics are key features of high quality primary care. Jerant noted that due to reduced health care access among uninsured and low-income populations, targeted interventions would be needed to ensure equitable access to quality primary care (Health Canal, 01/10). 6. Blacks’ Health Care: ‘Looking for Ways to Close The Gap’ in Maryland A recent article published in the Gazette discussed what some are doing to reduce health disparities among the black population in Prince George County, Maryland. According to the article, blacks disproportionally experience higher rates of infant mortality, hypertension, diabetes, and strokes than whites. Michael Chiaramonte, CEO of Southern Maryland Hospital, is part of a 10-member committee that is responsible for exploring health disparities among Maryland’s population. This committee will be rolling out a number of new initiatives that will help reduce health disparities according to the article. One of the initiatives includes increasing the number of primary care visits among the black population. According to the article, increasing primary care visits will be one way to dramatically reduce disparities in health outcomes for blacks. Some of the other areas leaders in Prince George County have been concerned about include bringing down costs of care. The cost of care, according to the article, is tied with increasing the number of primary care visits. “The key to reducing health costs has to do with getting the patient the right level of care at the right time,” said Chiaramonte (Robins, 1/09). 7. The Income Penalty for Diabetes: $160,000 A recent article published by Kaiser Health News discussed a recent study published in Health Affairs, which found that a young person with diabetes can expect to make $160,000 less in their lifetime and experience 0.25 fewer years of school than their peers. The study’s findings showed young diabetic adults are more likely to drop out of high school and make less money in their lifetime than their peers who do not have diabetes. “High school is relatively young to have such large effects,” said Jesse M. Fletcher, lead author and associate professor of health policy at the Yale School of Public Health. He continued by noting that this can potentially have a significant impact on society because a they are more likely to use food stamps and welfare, in addition to serve time in jail. Currently, the United States spends more than $200 billion each year for the cost of people with diabetes. Fletcher adds that this is concerning because the number of Americans with diabetes (23 million) is expected to increase as more Americans are becoming obese. The explanation for the loss of income and dropping out of high school varies according to the article. An employer being reluctant to hire a diabetic worker or an employee missing work due to poor health conditions Fletcher explains as potentially income loss factors. He also explained that a child missing school more often than their peers or costs are too high for families due to illness are potential factors associated with less education. Fletcher suggest future research will have to explore diabetic children at the elementary and junior high level to determine if early screening and intervention would be beneficial. The study used data from the 1994 and 2008 data files by the National Longitudinal Study of Adolescent Health. Although the study controlled for a number of different factors, a possible limitation included that the study did not distinguish between Type I or Type II diabetes (Gold, 1/09). 8. New Clues Revealed in Studies of Stillbirth According to a recent article published in The New York Times, two new studies have identified the most common risk factors and causes of stillbirths. Stillbirths occur in the United States at a higher rate than in many other developed nations. One team of researchers set out to identify risk factors that could predict stillbirths early in a pregnancy. A second team focused on identifying probable cause of death in 512 stillbirth cases. Both studies found significant and unexplained racial and ethnic variations. Black women were twice as likely to have a stillbirth, with the largest disparities occurring early in pregnancy. While black women were more likely to lose a child due to an infection, white and Hispanic women were more likely to lose a child due to umbilical cord abnormalities. The research teams concluded that additional research is needed to identify the causes of racial disparities. While some risk factors cannot be modified (such as a mother’s age or ethnicity), future studies may find additional risk factors that can be managed (Bakalar, 01/09). 9. Black Health Care Coalition Advocates for Health Choices A recent article published in the Kansas City Star discussed what a non-profit organization and its former chairman has done to improve the health of local black residents in the Greater Kansas City area. The Black Health Care Coalition, an organization that has launched a number of education and outreach campaigns targeted to local black residents of the Greater Kansas City area, which provided health screenings and lifestyle education seminars. The organization has spread its message and mission to local churches, community centers, and elsewhere according to the article. Although this organization targets the black population, Melissa Robinson, president and CEO of the Black Health Care Coalition, said no one is turned away and the goal is to improve the health of everyone. “By improving the population of the black community, it will improve the populations as a whole,” said Jasper Fullard, Jr., founder and now vital advisor to Black Health Care Coalition. Other initiatives included teaching residents to cook better and choose healthier foods, and have frequent health screenings. Certain challenges were highlighted in the article however. For example, local residents have limited accessible walking trails and grocery stores that offer fresh and affordable fruits and vegetables. Additionally, some retailers are staying away from operating in the urban areas of Kansas City, which many city leaders are frustrated about. “We will be fighting this for years and years to come. It’s an ongoing problem. It’s not a reason to grow weary or give up,” said Fullard. The Southern Christian Leadership Conference of Greater Kansas City will honor Fullard for his work to fight health disparities. Fullard founded the organization 26 years ago and the organization will continue to work on improving the health of local residents in the area (Bormann, 1/08). 10. Healthcare Plan for Low-Income Adults Includes Mental Health Benefit A recent article published in HealthyCal discussed a program that will help provide treatment to the millions of adults in California suffering from a mental illness before some of health reform’s mandates go into effect in 2014. A study by the UCLA Center for Health Policy Research found that roughly 2 million Californians need some sort of treatment for a mental illness. Additionally, no legislation in the state mandates coverage for mental health treatment according to the article. The study also found 87 percent of the uninsured adults with a mental illness go without treatment. “The need, we know, for many is enormous,” said Rusty Selix, executive director of the Mental Health Association in California. A state and federal program will now bring relief and needed services to the millions of individuals before the 2014 mandates are set to go into effect. Some of the health benefits include up to 10 days of acute inpatient treatment per year and a total of 12 days per year of outpatient treatments. According to the article, this program is designed for low-income individuals suffering from a mental illness. However, a mental illness, e.g. schizophrenia, runs through all the populations of different income levels. So the program does permit eligibility those with a slightly higher income. Despite the benefits, the program does face some potential challenges, e.g. providing enough mental health, substance abuse care, and bi-lingual providers. “The compensation is so low. Services are usually provided by community-based groups, non-profits, and their funding has been reduced,” said Louise Rogers, deputy chief of San Mateo County’s health system. Despite the challenges, Rogers estimates that 3,300 people who are in need of mental health and substance abuse care in San Mateo, CA will now receive the care they need. Additionally, many mental health officials around the state are happy that this will give California a head start before the 2014 mandates are set to go into effect according to the article (Moran, 1/08). 11. NAMI Program Offers Life Coaching to Those with Mental Illnesses Be Well, a program similar to Weight Watchers, provides peer- support and health education to those struggling with a mental illness in Wisconsin, the Appleton Post Crescent reports. People living with a mental illness live 25 years or less than those who do not have a mental illness. Additionally, a mental illness is often linked to low socioeconomic and social status according to the article. Be Well, a program started by the Fox Valley chapter of National Alliance on Mental Illness (NAMI), is attempting to address these health issues. The program primarily provides education and support to those who are most vulnerable. Be Well, which functions similar to Weight Watchers, is a support system of peers who all are struggling with a mental illness and each participant learns about nutrition, sleep, medication side effects and tobacco use. “It’s a wonderful pairing; it’s very motivating. Lots of people learned things they never knew about how to eat well, how medications worked and why they were so unmotivated to work or get out,” said Beth Clay, executive director of NAMI Fox Valley. Volunteers are also a component of the program according to the article. For example, Rebecca Arrowood, a student from the University of Wisconsin-Green Bay, is responsible for lining up speakers for the 12 week program. Jen Parsons, a personal trainer and NAMI Fox Valley volunteer for nearly eight years, plays a role in the Be Well wellness program. Overall, the program was a huge success and is benefitting so many individuals on so many levels,” said Parsons. The 12 week program begins again January 18th (Anderson, 1/08). 12. Family Support Motivates Mexican-Americans to Adopt Healthy Habits A recent article published in Health Behavior News Service discussed a study which found that encouragement from family members helped Mexican-Americans improve their diet and fitness behaviors. Obesity is more prevalent in Mexican-Americans populations than among their non-Hispanic white peers. In a new study, researchers from the University of Memphis investigated the health behaviors of 161 multi-generational Mexican-American families. Participants received personalized information regarding family history, risk of chronic disease, and information about healthy lifestyle changes. The study followed up with participants over time to learn more about ongoing dietary and fitness choices, motivation levels, and the potential influence of encouragement from family and friends. The study concluded that that having at least one supportive friend or family member motivated participants to live healthier lives. According to lead study researcher Dr. Sato Ashida, these findings demonstrate that “influence from [social] network members provides a potentially culturally appropriate strategy to motivate individual behavior change.” Participants who received encouragement from loved ones were more likely to engage in regular exercise and eat more fruits and vegetables (Kennedy, 01/05). 13. Cancer Deaths Drop, But Incidence Rises A recent article published in Medscape Medical News discussed a new report highlighting recent reductions in cancer related deaths and rising incidence rates for seven types of cancer. Overall, cancer mortality rates have declined in recent years. However, considerable geographic, racial, and ethnic variation in cancer incidence and mortality continues to exist. Notably, due to regional smoking behaviors, lung cancer is four times more prevalent in Kentucky than in Utah. Cancer incidence and death rates are also consistently higher for blacks than for whites, with some variation across gender and cancerous condition. For example, black men are 15% more likely to be diagnosed with cancer and 33% more likely to die from cancer than to white men. Compared to blacks and whites, all other minority groups had lower rates of cancer incidence and mortality. In the last decade, incidence rates of cancers of the pancreas, liver, thyroid, kidney, and melanoma have all increased. In addition, esophageal adenocarcinoma and oropharyngeal cancer rates have also increased. Further research is needed to better understand these trends and determine if more diagnoses are being made due to better technology or if incidence rates are truly on the rise (Nelson, 01/05). 14. In Extreme Old Age, Blacks Outlive Whites on Average According to a recent article from Newsworks, elderly blacks live longer than elderly whites. Despite reduced life expectancies from birth through adulthood, there is a reversal of trends for blacks who live beyond 80 years of age. According to Duke University researcher Keith Whitfield, African Americans who live to extreme old age “are actually a very, very select group of people who have resilient factors.” Many of these African Americans, who have lived to extreme old age, did so despite the many chronic diseases that disproportionately affect and reduce life expectancy for blacks including: high blood pressure, stroke, diabetes. According to Whitfield, the exceptional resilience of this group is likely attributable to a combination of genetic and behavioral factors. Effective stress management skills may have provided protective health benefits for elderly African Americans, many of whom lived through times of heightened violence and discrimination (English, 01/02). 15. Diagnosis, Treatment of Depression Among Elderly Depend On Racial, Cultural Factors A recent article published by Medical News Today, highlights racial and ethnic disparities in depression care among the elderly. Depression can significantly diminish quality of life and complicate coexisting medical conditions. For this reason, depression is a significant public health issue for elderly populations. A new study from Rutgers University found that elderly African Americans are significantly less likely to be appropriately diagnosed or treated for depression. Lead study researcher Ayse Akincigil noted that “help-seeking patterns differ by race/ethnicity, contributing to the gap in depression diagnosis rates.” The study also indicated that shame, denial, and insurance status may also be significant obstacles for black patients struggling with depression. The study concludes that additional measures must be taken to “reduce the burden of undetected and untreated depression and to identify the barriers that generate disparities.” According to the researchers, universal depression screening and increases in treatment reimbursement rates may be effective in increasing access to appropriate care for low-income and minority patients (Medical News Today, 01/02). DISPARITIES IN RESEARCH 16. Trends in Melanoma Mortality Among Non-Hispanic Whites by Educational Attainment, 1993 – 2007 A recent study published in Archives of Dermatology found educational attainment and death from melanoma to be strongly associated with non-Hispanic whites. According to the study, research has found an association between socioeconomic status (SES) and survival among melanoma patients. In this study, the researchers used data from the National Vital Statistics System for the years of 1993 through 2007 to examine the relationship between education and melanoma mortality in young and middle-aged non-Hispanic white adults. The researchers analyzed data from the 26 states that were collecting information on education in 1993. Education as categorized into three levels: less than 12 years (did not complete high school), 12 years (high school graduate or equivalent), or 13 years or more (some college or college graduate). Several years of data were combined to create three categories: 1993-1997, 1998-2002, and 2003-2007. A total of 21,230 deaths were reported from 1993 through 2007. The results indicated there was an overall decrease in mortality rates for both white men and women decreased from 1993 to 2007. These declines, however, were only statistically significant among those who had some college or higher. Mortality rates among the least educated remain statistically unchanged between 1993 and 2007. The study also found higher melanoma mortality rates among the least educated. This change created a significant SES disparity in melanoma mortality in 2003 – 2007 relative to 1993 – 1997. This disparity increased roughly 51 percent for men and 35 percent in women. The authors concluded that persistent disparity of melanoma mortality rates among low SES individuals and the widening gap by educational attainment calls for more targeted programs. For example, educational programs that target high-risk subgroups of low SES. (Cokkinides VE, Geller AC, Jemal A. Trends in melanoma mortality among non-Hispanic whites by educational attainment, 1993 – 2007. Archives of Dermatology. 2012 Jan; doi:10.1001/archdermatol.2011.2779). 17. Lower Socioeconomic Status and Disability Among US Adults With Chronic Kidney Disease, 1999 – 2008 A recent study published by the Centers for Disease Control and Prevention: Preventing Chronic Disease found people living in a lower socioeconomic status (SES) with chronic kidney disease (CKD) have a greater risk of developing a disability. Prior research has demonstrated a relationship between disability and chronic kidney disease, a relationship between SES and the development and progression of CKD, and a relationship between SES and disability, but few studies have determined whether there is a relationship between SES and disability in patients with CKD. The study used data from a nine-year merged file of the National Health and Nutrition Examination Survey (NHANES), 1999 – 2008. The sample size for analysis was 4,257. Inclusion requirements included a participant whose serum creatinine, urinary creatinine, and urinary albumin measurements indicated CKD and were 20 years of age or older. The participants were asked if any of the following disabilities were caused by CKD: difficulty performing activities of daily living (ADL) instrumental ADL, lower-extremity mobility (LEM), and leisure and social activities (LSA). The majority of participants reported some type of disability caused by CKD according to the findings. For example, after adjusting for age and sex, 1 in 5 persons reported ADL limitations. The most prevalent type of disability among participants was LEM (50%). The ADL prevalence rate for blacks and Mexican Americans was higher than whites. However, race and ethnicity was not a factor for developing a disability due to CKD—except for ADL—after adjusting for sociodemographic factors, health care access, and other clinical variables. Furthermore, a lower prevalence of a disability was associated with participants with higher levels of education and income. The linear association between socioeconomic status (SES) and developing a disability dude to CKD reinforces the notion that health outcomes and health status tend to be worse for those in a lower SES according to the authors. One explanation for this disparity is the cost barriers associated with care and management for CKD. The authors indicate that this study was important because it highlighted how health outcomes for people with CKD in a lower SES are worse. Further research will have to explore this association and discover possible mechanisms that are targeted towards lower education or income levels earlier in order to prevent further loss of income due to worse health outcomes. (Plantinga CL, Johansen KL, Schillinger D, et al. Lower socioeconomic status and disability among US adults with chronic kidney disease, 1999 – 2008. Centers for Disease Control and Prevention: Preventing Chronic Disease. 2012 Jan; 9(ISSN: 1545- 1151). 18. Hispanic Lesbians and Bisexual Women at Heightened Risk or Health Disparities A recent study published in the American Journal of Public Health found Hispanic lesbian and bisexual women tend to be at a greater risk of worse health outcomes than Hispanic heterosexual as well as white lesbian and bisexual women. Little background literature covers health disparities among sexual minorities of color, especially Hispanics, according to the authors. This study aims to explore how Hispanic sexual minorities fare in health care access, health outcomes, health status, and health risk behaviors. The study used the weighted-data from a 7- year merged file of the Washington State Behavioral Risk Factor Surveillance System (BRFSS), 2003 – 2009. The sample size for the analysis was 6,338. Only Hispanic and white women who self- identified as lesbian, bisexual, or heterosexual were included in the study. Within the sample, 1.1% were Hispanic lesbian and 1.6% were Hispanic bisexual. Data were collected for health status, health risk behaviors, health outcomes, and health care access. Hispanic lesbian and bisexual women did not differ from white lesbian and bisexual women for many health and demographic indicators, but some differences were observed. For example, Hispanic lesbian women tended to have a higher prevalence of lifetime asthma than all the other groups. Furthermore, Hispanic lesbian women also reported higher smoking rates and lower exercise rates than Hispanic heterosexual women. Hispanic bisexual women tended to have higher rates of mental distress and worse general health than both white and Hispanic heterosexual women as well as white lesbian and bisexual women. This study is one of the first studies to assess disparities among Hispanic lesbian and bisexual women according to the authors. The authors suggest that further research is needed in order to develop culturally appropriate programs that meet the needs of these subgroups. This in turn, as the authors argue, will achieve the goals laid out Healthy People 2020. (Kim HJ, Fredriksen-Goldsen K. Hispanic lesbians and bisexual women at heightened risk or health disparities. American Journal of Public Health. 2012 Jan; 102(1): 9 – 15). 19. Characteristics Associated with the Initiation of Radiation Therapy After Breast-Conserving Surgery among African American and White Women Diagnosed with Early-Stage Breast Cancer in Maryland, 2000 – 2006 A recent study published in Annals of Epidemiology found that between 2000 and 2006, black women of a lower socioeconomic status (SES) in Maryland were less likely to use radiation therapy (RT) after breast-conserving surgery (BCS) than white women. Prior research has found RT after BCS improves the quality of life. However, the proportion of patients not undergoing RT after BCS has almost doubled in the years between 1989 to 1995 (10% to 19%) according to the authors. This study aims to explore what factors are associated with receiving an RT after BCS in Maryland. This study concentrated only on black and white women with early-stage breast cancer who received a BCS from 2000 to 2006 in Maryland. The data used for the study was retrieved from the Maryland Cancer Registry (MCR), which releases quarterly reports about all human cancer cases that occur in the state. The primary interest was if a patient was considered low income. The study’s standard for low income was if 1) the patient was insured through Medicaid, 2) resided in a zip code with a median family income lower than the 250% of the federal poverty level (FPL) in 1999 (less than an annual income of $42,575.50 for a family of four), or 3) the patient received services from the Maryland Breast and Cervical Cancer Screening Program or the Maryland Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDTP). The outcome of interest was whether the patient did have an RT after a BCS. Of the total 14,971 breast cancer patients, 23% were black while 77% were white. Women who had private insurance and/or had a tumor size less than or equal to 2 cm were more likely to use RT after BCS according to the findings. Patients who were less likely to use radiation tended to be 80 years of age or older, low income, and black. According to the authors, this study confirming racial and socioeconomic disparities among women with breast cancer was consistent with the literature. Although black women were 17% less likely to use RT, this disparity decreased after 2003 according to the findings. The authors argue future research will need to explore the uptake of RT and other prescribed treatments after BCS. (Royak-Schaler R, Pelser C, Langenberg P, et al. Characteristics associated with the initiation of radiation therapy after breast- conserving surgery among African American and white women diagnosed with early-stage breast cancer in Maryland, 2000 – 2006. Annals of Epidemiology. 2012 Jan; 22(1): 29 – 36). 20. Medical Expenditures Among Immigrant and Nonimmigrant Groups in the United States A recent study published in Medical Care found medical expenditures among immigrants (non-citizens and foreign born) were disproportionally lower than non-immigrants (US citizens) and were more likely to not have a usual source of care. Not much has contributed to the literature about expenditures and cost of care among immigrants in the United States. This study investigated the medical expenditures and costs incurred between non-citizens, foreign-born, and US-born citizens. They used data from a nine year merged file of the Medical Expenditures Panel Survey (MEPS). The MEPS combined data file was linked with the data from the National Health Interview Survey (NHIS), which was created by the Agency for health care Research Quality staff. These two data files were linked in order to identify the immigration status of a respondent. A total of 190,965 non-institutionalized US adults, older than 18 years of age, were included in the study’s sample. The outcome of interest was whether immigration status had an influence on the amount of self-reported health care expenditures. The independent factors included race and ethnicity, age, gender, education. The “enabling” factors included household income, insurance status, and availability of a usual source of care. The results varied, especially in the total amount of expenditures between groups and what was the primary source for their medical expenditures. For example, non-citizens largely used out-of-pocket sources, while US born citizens relied largely on private coverage. Public sources had the most variation throughout the study period. Consistently, foreign born citizens largely used public coverage; however, non-citizens relied more on public aid than US born citizens in the earlier years of the study. This dissipated by 2002 and non-citizens rarely used public aid. Despite non-citizens relying heavily on using out-of-pocket methods, non- citizens spent far less on medical costs than any other group according to the findings. This study is consistent with literature according to the authors. The low expenditure among non-citizens can be an explanatory factor for why they tend to experience worse health outcomes. Additionally, these results suggest that extending health insurance coverage, increasing awareness about centralized health care, and usual source of care access could potentially provide an equitable health care system for all the authors argue. (Tarraf W, Miranda PY, Gonzŕlez HM. Medical expenditures among immigrant and nonimmigrant groups in the United States: findings from the Medical Expenditures Panel Survey (2000 – 2008). Medical Care. 2012 Jan; doi: 10.1097/MLR.0b013e318241e5c2). 21. Impact of Electronic Health Records on Racial and Ethnic Disparities in Blood Pressure Control at US Primary Care Visits A recent study published in Archives of Internal Medicine found that black and white patients experience similar levels of blood pressure if they visit a doctor who uses electronic health records (EHR) with clinical decision support (CDS). Prior research has indicated improved blood pressure among patients whose doctor used both electronic health records (EHR) and clinical decision support (CDS). For this study, the researchers sought to determine whether the benefits achieved are shared equally among patients of different racial and ethnic backgrounds. Using data from the National Ambulatory Medical Care Survey (NAMCS, which is a nationally representative survey of primary care visits by the National Center for Health Statistics (NCHS), the primary outcome of interest was whether a patient’s blood pressure improved. Visits were grouped by race and ethnicity and whether the patient visited a doctor who used EHR and/or CDS. Analyses controlled for age, sex, diabetes, practice ownership, and insurance type of insurance. Patients who visited a doctor that used both EHRs and CDS experienced improved levels of blood pressure, and Hispanic patients experienced significant improvement. The results also showed that there was no disparity between the black and white patients whose providers used HER and/or CDS. However, racial disparities persisted for the black patients who visited a doctor that did not use EHR and CDS. The authors suggested these findings highlighted primary care may reduce morbidity and mortality from cardiovascular disease and reduce blood pressure control disparities by implementing EHRs with CDS. (Dal Pan GJ, Temple R. Impact of electronic health records on racial and ethnic disparities in blood pressure control at US primary care visits. Archives of Internal Medicine. 2012 Jan; 172 (1): 75 – 76). 22. The Impact of Socioeconomic Inequalities and Lack of Health Insurance on Physical Functioning Among Middle-Aged and Older Adults in the United States A recent study published in Health and Social Care in the Community found that having more financial resources and private health insurance predicted better physical functioning over time. Prior research has shown that individuals with lower socioeconomic status have higher rates of mortality and morbidity. This study sought to determine how socioeconomic status and lack of private health insurance influence physical functioning later in life. The study used 1994 – 2006 data from the Health and Retirement Study (HRS), a national longitudinal panel study of adults over 50 years of age and their spouses. The researchers selected a sample of 6,519 adults who provided complete information regarding their health, socioeconomic, financial, and health insurance status. Due to small sample sizes for other racial groups, only white and black adults were included in the sample. In the HRS dataset, respondents provided information on gender, race, household income, household assets, educational attainment, and enrollment in private health insurance. Physical function was the primary outcome variable of this study. This variable was defined as level of difficulty with any of five basic activities of daily living (ADL): walking across a room, bathing, eating, dressing, and getting into and out of bed. The researchers included several control variables including age at baseline, marital status, employment status, and birth cohorts to control for any historical effects. The study found that having more financial resources and private insurance were significant predictors of better physical functioning across racial groups. After controlling for socioeconomic status, declines in physical function were similar across racial groups. However, changes in socioeconomic status resulted in greater improvements in physical functioning for women than for men. As the socioeconomic gap narrowed with age, the researchers also found that the impact of educational attainment, gender, and race on physical functioning diminished over time. These findings were consistent with previous research findings indicating that the economically disadvantaged are more likely to experience more rapid declines in physical functioning. In light of these findings, the researchers indicate that policy interventions are needed to reduce the negative impact of socioeconomic inequalities on physical functioning. Future research is also needed to consider how education may contribute to racial disparities in physical functioning. (Kim J, Richardson V. The impact of socioeconomic inequalities and lack of health insurance on physical functioning among middle-aged and older adults in the United States. Health and Social Care in the Community. 2012 Jan; 20(1): 42 – 51). 23. Children With Cerebral Palsy: Racial Disparities in Functional Limitations A recent study published in Epidemiology found that cerebral palsy is generally more prevalent among black children compared to white children, with the most striking disparities occurring among those with severe functional limitations. Cerebral palsy is a developmental disability that impairs motor function. While prior research has demonstrated that cerebral palsy ranges in severity, it is unclear if racial and ethnic disparities exist in the prevalence of this disease. This study sought to understand if cerebral palsy is more prevalent among black children, considering the full spectrum of functional limitations. The study used 2006 surveillance data from Centers for Disease Control’s Autism and Developmental Disabilities Network (ADDM) to identify 8-year-old children with cerebral palsy residing in Alabama, Georgia, Missouri, and Wisconsin. The researchers included a sample of 476 children with mild, moderate, severe, and unknown motor skill limitations due to cerebral palsy. To better understand potential racial disparities across levels of functional limitation, the researchers used multiple imputation models to stratify cases by severity and better understand the health status of children missing motor limit classifications. The imputation models revealed that children missing motor limit classifications were more likely to have milder symptoms. Using this adjusted analysis, researchers found that racial disparities only existed among children with severe motor limitations. Black children were 70% more likely to have severe cerebral palsy than white children. These findings were consistent with previous research highlighting the prevalence and severity of cerebral palsy among non-Hispanic black children. The authors indicate that there is a complex relationship between race and the prevalence and severity of cerebral palsy. It is not yet clear if there is differential ascertainment of the disease or if access to care plays a larger role creating racial disparities. Further research is also needed to generalize these studies to children of other racial and ethnic backgrounds. (Maenner MJ, Benedict RE, Arneson CK, et al. Children with cerebral palsy: racial disparities in functional limitations. Epidemiology. 2012 Jan; 23(1): 35 – 43). 24. Disability Among Lesbian, Gay, and Bisexual Adults: Disparities in Prevalence and Risk A recent study published in the American Journal of Public Health found higher rates of disability among lesbian, gay, and bisexual (LGB) adults in Washington state. Almost 50 million American adults have disabilities and many require specialized care on a daily basis. This study sought to examine patterns of disability by sexual orientation to understand if LGB populations are especially vulnerable. The researchers analyzed four years of Behavioral Risk Factor Surveillance System (BRFSS) data to examine the health status of 82,531 adults living in Washington State. The study was limited to English or Spanish speaking adults who self-identified as: heterosexual, lesbian, gay, or bisexual. The primary outcome was self-reported disability status, defined as any physical, mental, or emotions problems limiting daily life. The researchers captured several sociodemographic variables including: racial identity (white or non-white); age; relationship status (married, partnered, or other); household income; and educational attainment. The study also captured several covariates of disability including: chronic health conditions, health risk behaviors, and physical and mental health status. The study found that sexual orientation was predictive of disability and that higher rates of disability occur among LGB populations, especially among lesbians and bisexual adults. These findings are consistent with prior research indicating that non-heterosexual populations experience disparities in physical and mental health. The authors indicated that disability rates among gay men may be decreased by addressing specific high risk behaviors (such as smoking) and mental distress. However, researchers believe this strategy would be less effective in reducing disability among bisexuals and lesbians. Additional research is needed to understand the role stress and stigma may play in increasing the prevalence of disability among LGB populations. (Fredriksen-Goldsen KI, Kim HJ, Barkan SE. Disability among lesbian, gay, and bisexual adults: disparities in prevalence and risk. American Journal of Public Health. 2012 Jan; 102(1): 16 – 21). 25. Racial and Ethnic Disparities in Obesity During the Transition to Adulthood: The Contingent and Nonlinear Impact of Neighborhood Disadvantage A recent study published in the Journal of Youth and Adolescence found that neighborhood disadvantage increases the risk of obesity and partially explains racial and ethnic disparities in obesity among young women. Children who are obese during adolescence are at risk of developing additional health complications as they enter adulthood. This study sought to determine the influence of neighborhood economic disadvantaged on the onset of obesity in young adults across racial and ethnic groups. Using 1994 data from the National Longitudinal Study of Adolescent Health (Add Health), the study analyzed the health status of 5,759 teenagers. The key variables included in the study were obesity (obese or not obese); gender; race and ethnicity (black, white, or Hispanic); and neighborhood disadvantage (a measure of economic insecurity at the census tract level). The authors found that black and Hispanic teenage girls were nearly twice as likely to become obese compared to white girls. Black boys were slightly more likely to become obese compared to white boys. The study also found neighborhood disadvantage to be significant predictor of obesity among teenage girls. While this variable explained much of the disparity between black and white girls, it minimally explained the disparity between Hispanic and white girls. The authors concluded that policy interventions improving public safety and access to nutritious food in disadvantage neighborhoods will help reduce childhood obesity. However, additional research is needed to better understanding the factors contributing to obesity among Hispanic girls. (Nicholson LM, Browning CR. Racial and ethnic disparities in obesity during the transition to adulthood: the contingent and nonlinear impact of neighborhood disadvantage. Journal of Youth and Adolescence. 2012 Jan; 41(1): 53 – 66). Financial and Educational Worries by Race
The results of a new poll by the Kaiser Family Foundation and the Washington Post found fewer black women said they frequently experienced stress than white women, but more black women than white women are worried about certain aspects of their life. Nearly 2 in 5 black women and 1 in 4 white women with children are very worried about being able to provide a good education their children, and almost 2 in 5 black women and 3 in 10 white women are very worried about having enough money to pay their bills. These are some of the findings highlighted in a new poll from the Washington Post and the Kaiser Family Foundation. The poll was conducted by telephone, and included nearly 2,000 adults. It asked covered a variety of topics from self-esteem and stress to perceptions of Michelle Obama. To learn more about the poll,
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