The role of race and poverty on steps to kidney transplantation in the Southeastern United States.

Racial disparities in access to renal transplantation exist, but the effects of race and socioeconomic status (SES) on early steps of renal transplantation have not been well explored. Adult patients referred for renal transplant evaluation at a single transplant center in the Southeastern United States from 2005 to 2007, followed through May 2010, were examined. Demographic and clinical data were obtained from patient's medical records and then linked with United States Renal Data System and American Community Survey Census data. Cox models examined the effect of race on referral, evaluation, waitlisting and organ receipt. Of 2291 patients, 64.9% were black, the mean age was 49.4 years and 33.6% lived in poor neighborhoods. Racial disparities were observed in access to referral, transplant evaluation, waitlisting and organ receipt. SES explained almost one-third of the lower rate of transplant among black versus white patients, but even after adjustment for demographic, clinical and SES factors, blacks had a 59% lower rate of transplant than whites (hazard ratio = 0.41; 95% confidence interval: 0.28-0.58). Results suggest that improving access to healthcare may reduce some, but not all, of the racial disparities in access to kidney transplantation.

Racial disparities in pediatric access to kidney transplantation: does socioeconomic status play a role?

Racial disparities persist in access to renal transplantation in the United States, but the degree to which patient and neighborhood socioeconomic status (SES) impacts racial disparities in deceased donor renal transplantation access has not been examined in the pediatric and adolescent end-stage renal disease (ESRD) population. We examined the interplay of race and SES in a population-based cohort of all incident pediatric ESRD patients <21 years from the United States Renal Data System from 2000 to 2008, followed through September 2009. Of 8452 patients included, 30.8% were black, 27.6% white-Hispanic, 44.3% female and 28.0% lived in poor neighborhoods. A total of 63.4% of the study population was placed on the waiting list and 32.5% received a deceased donor transplant. Racial disparities persisted in transplant even after adjustment for SES, where minorities were less likely to receive a transplant compared to whites, and this disparity was more pronounced among patients 18-20 years. Disparities in access to the waiting list were mitigated in Hispanic patients with private health insurance. Our study suggests that racial disparities in transplant access worsen as pediatric patients transition into young adulthood, and that SES does not explain all of the racial differences in access to kidney transplantation.

Depression in black and white women. The role of marriage and socioeconomic status.

The degree to which the relationship between race and depression in US black and white women is modified by socioeconomic and marital status was investigated. Data on 534 black and 836 white women, 25 to 64 years old, obtained from the 1986 Americans' Changing Lives national survey were utilized. Depression was measured by the Centers for Epidemiologic Studies Depression scale. Poverty status and education were used as indicators of socioeconomic status (SES). For both black and white women, the prevalence of depression was higher among those with lower as compared to higher SES, and among the unmarried as compared to the married. The unstratified, age-adjusted odds of depression for black women was twice that for white women (odds ratio (OR) = 2.2; 95% confidence interval (CI), 1.7 to 2.8); however, when stratified by poverty status, race effects were observed for nonpoor (OR = 2.2; 95% CI, 1.6 to 3.0) but not for poor women (OR = 1.3; 95% CI, 0.7 to 2.1). Race effects were also more pronounced among married (OR = 2.0; 95% CI, 1.4 to 2.9) than unmarried women (OR = 1.6; 95% CI, 1.1 to 2.4). Controlling for known confounders did not alter these results. Additional analyses revealed that the black excess risk for depression was concentrated among higher SES, married women, with marital difficulties appearing to pay a major role in their elevated depression scores.

Reading skills and family planning knowledge and practices in a low-income managed-care population.

OBJECTIVE: To examine the relationship between reading ability and family planning knowledge and practices among Medicaid managed care enrollees. METHODS: A total of 406 women age 19-45 years enrolled in TennCare and members of Prudential HealthCare Community Plan in Memphis, Tennessee were interviewed to determine their methods of contraception, desire for additional information about contraceptives, and knowledge about the time in menstrual cycle they are at highest risk for pregnancy. Patient reading ability was assessed by an abbreviated version of the Test of Functional Health Literacy of Adults. The independent associations between reading ability, desire for additional contraceptive information, and knowledge about the highest risk time for pregnancy were assessed with logistic regression. RESULTS: Almost 10% of the respondents had low reading skills. Women who had used an intrauterine device, douching, rhythm, or levonorgestrel implants as methods of birth control had higher rates of low reading skills than women who used other methods of birth control. Compared with women with good reading skills, women with low reading skills were 2.2 times (95% confidence interval [CI] 1.1, 4.4) more likely to want to know more about birth control methods and 4.4 times (95% CI 2.2, 9.0) more likely to have incorrect knowledge about when they were most likely to get pregnant. These relationships were significant even after controlling for age, race, and marital status. CONCLUSION: Health providers and organizations that serve historically underserved populations must understand that some individuals have a low level of reading ability that limits family planning education.

Prenatal care for low-income women enrolled in a managed-care organization.

OBJECTIVE: To determine barriers to prenatal care among managed-care enrollees who receive Medicaid. METHODS: In-person interviews were conducted with women 13-45 years old who were members of the Prudential HealthCare Community Plan in Memphis, Tennessee. Interview data were linked to medical chart reviews for 200 women who were currently pregnant or had delivered a baby since enrollment in Prudential. Factors related to untimely entry to prenatal care and inadequate prenatal visits were examined. RESULTS: More than half of the respondents had either untimely entry to or inadequate prenatal care. Overall, 89% of respondents had favorable attitudes about prenatal care. Several system and personal factors were associated with receipt of early or adequate prenatal care. Multivariate analysis showed that one system and two personal factors remained significantly related to entry to prenatal care. Women who entered Prudential during pregnancy were 2.4 times more likely (95% CI 1.1, 5.0) to receive late care than women who enrolled before pregnancy. Women who felt too tired to go for care were 2.2 times more likely (95% CI 1.0, 4.9) to receive late care. Women who experienced physical violence during pregnancy were 3.5 times more likely (95% CI 1.0, 12.0) to receive late care. Multivariate analysis with adequacy of prenatal care as the outcome showed several personal factors that increased odds of receiving inadequate prenatal care; however, only help from the infant's father was significantly related to adequacy of prenatal care. Women who did not have much help from the infant's father were 1.9 times more likely not to have adequate care (95% CI 1.0, 3.6). CONCLUSION: Even when affordable care was available, many low-income women did not avail themselves of it. Although women knew the importance of prenatal care, there was a gap between attitudes and actually seeking appropriate care. System and personal factors need to be addressed to overcome barriers to prenatal care.

The relationship between pregnancy intendedness and physical violence in mothers of newborns. The PRAMS Working Group.

OBJECTIVE: To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. METHODS: Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. RESULTS: The state-specific prevalences (+/- standard error) of physical violence ranged from 3.8 +/- 0.5 to 6.9 +/- 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9-46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7-6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. CONCLUSION: Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

Delayed entry into prenatal care: effect of physical violence.

OBJECTIVE: To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence. METHODS: We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993-1994 in nine states and were surveyed 2-6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care. RESULTS: The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status. CONCLUSION: Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.

Maternity experiences in a managed care organization.

We conducted a telephone survey of female managed care enrollees who recently had a normal vaginal delivery to examine the relationship between hospital length-of-stay and maternal characteristics, pregnancy factors, length-of-stay preferences, and postdischarge experiences. Results indicated that length-of-stay varied by maternal characteristics and pregnancy factors. Length-of-stay and maternal or newborn readmissions were not statistically associated. Most respondents reported that they would be willing to go home within twenty-four hours after future deliveries if additional services were provided. Emphasis should be placed on which services can be provided to prepare and assist mothers through the perinatal period.

Associations between measures of socioeconomic status and maternal health behavior.

Lower socioeconomic status (SES) is consistently associated with adverse pregnancy outcomes. One mechanism that may account for this association is that maternal health behaviors vary with SES. To examine this possibility, we addressed how women may be differently categorized by diverse measures of SES and the effect that choice of measure has on the relationship between SES and maternal health behaviors. We used population-based data for Caucasian women (n = 10,055) from Alaska, Maine, Oklahoma, and West Virginia who delivered a live infant in 1990-1991 and participated in the Pregnancy Risk Assessment Monitoring System. Five SES measures were evaluated: education; poverty status; Medicaid payment for delivery; Women, Infants, and Children (WIC) enrollment during pregnancy; and residential crowding. Three maternal health behaviors (smoking, delayed/no prenatal care, unintended pregnancy) were examined to assess the variation among the associations between SES measures and behaviors. Item response rates were high for all SES measures (range: 88.9%-100.0%), and there was low correlation between measures. Most of the SES measures were related to maternal health behaviors. However, the strength of association varied between each measure and behavior and was weaker for women who were younger than 20 years old or not married. In view of the multifaceted nature of SES, several measures may be needed to appropriately assess the relationship between SES and maternal health behaviors.

Violence and adverse pregnancy outcomes: a review of the literature and directions for future research.

INTRODUCTION: Violence during pregnancy has been estimated to affect between 0.9% and 20.1% of pregnant women in the United States. This article presents a review of the research on the potential association between violence during pregnancy and adverse outcomes, explores mechanisms by which violence might influence pregnancy outcomes, and suggests directions for future research aimed at the development of successful interventions. METHODS: A review of the literature pertaining to violence during pregnancy and adverse pregnancy outcomes, trauma, and stress during pregnancy was completed. RESULTS: Overall, no pregnancy outcome was consistently found to be associated with violence during pregnancy. The trauma literature offers insight about the effects that injuries caused by physical violence might have on pregnancy outcomes. Information from the stress literature investigates potential mechanisms through which physical violence could indirectly affect pregnancy outcomes. The trauma and stress literature offers methodologic approaches that could be employed in future research on violence during pregnancy and pregnancy outcomes. CONCLUSIONS: This review lays the groundwork for the development of a future research agenda to investigate the association between violence during pregnancy and adverse outcomes. Future research should include quantitative and qualitative approaches, and investigation into the mechanisms and antecedents of how violence during pregnancy may lead to adverse outcomes. Only with such information can successful interventions to limit violence and its potential effects during pregnancy be implemented.

Physician characteristics and the initiation of beta-adrenergic blocking agent therapy after acute myocardial infarction in a managed care population.

OBJECTIVE: To determine the association between physician characteristics and the use of beta-adrenergic blocking agents after acute myocardial infarction in a national managed care organization. STUDY DESIGN: Retrospective administrative data analysis. PARTICIPANTS AND METHODS: The study cohort consisted of 473 physicians who prescribed the medications and 578 patients who (1) experienced an acute myocardial infarction between January 1, 1995, and December 31, 1996, with at least 1 cardiac medication claim within 7 days of hospital discharge; (2) were not previously taking beta-adrenergic blocking agents; and (3) had none of several defined contraindications to the medication. Using multivariate models, we assessed the relation between physician characteristics and initiation of beta-adrenergic blocking agent therapy, controlling for patient characteristics and cardiac treatments. RESULTS: Sixty-two percent of patients filled a prescription for beta-adrenergic blocking agents within 7 days of hospital discharge. Physician characteristics, including specialty and region of hospitalization, were independently associated with the use beta-adrenergic blocking agents. Family practice physicians and other noninternists were much less likely than cardiologists to prescribe beta-adrenergic blocking agents. The other most important predictors of the use of beta-adrenergic blocking agents were region of hospitalization and patient age. CONCLUSIONS: Physician characteristics are associated with the use of beta-adrenergic blocking agents. Although there are opportunities to improve practice for all physicians, family practice physicians and noninternists have the most opportunity to improve.

How contraceptive use patterns differ by pregnancy intention: implications for counseling.

To increase awareness of issues to include in contraceptive counseling-the objectives of this study were to evaluate: 1) how contraceptive use patterns (eg, non-use), level of effectiveness of contraceptive method, and sociodemographic characteristics may be associated with the occurrence of unintended pregnancy; 2) patterns of health care use for women with intended and unintended pregnancy; and 3) the association between contraceptive use patterns and sociodemographic characteristics. In-person interviews were conducted with 279 women enrolled in a Medicaid managed care health plan who had been pregnant in the last 5 years. Self-reported measures of pregnancy intention, contraceptive use, and health care use were collected. The relationships of pregnancy intention with contraceptive use patterns, level of effectiveness of contraceptive method used, and patterns of recent health care use were assessed. Differences in contraceptive use patterns by sociodemographic groups were assessed. Seventy-eight percent of women reported an unintended pregnancy. Non-use of birth control the month before conception was reported by 57% of women with unintended pregnancies and 84% of women with intended pregnancies. Use of birth control of low effectiveness was reported by 20% of women with unintended pregnancies and 8% of women with intended pregnancies. Non-use or use of contraceptive methods of low effectiveness did not differ for women in different sociodemographic groups regardless of pregnancy intention status. A majority of women reported recent health care use. Health care providers should be aware that women who have no intention for pregnancy may not be using an effective contraceptive method NOR have an effective pattern of contraceptive use.

Development of a brief test to measure functional health literacy.

We describe the development of an abbreviated version of the Test of Functional Health Literacy in Adults (TOFHLA) to measure patients' ability to read and understand health-related materials. The TOFHLA was reduced from 17 Numeracy items and 3 prose passages to 4 Numeracy items and 2 prose passages (S-TOFHLA). The maximum time for administration was reduced from 22 minutes to 12. In a group of 211 patients given the S-TOFHLA, Cronbach's alpha was 0.68 for the 4 Numeracy items and 0.97 for the 36 items in the 2 prose passages. The correlation (Spearman) between the S-TOFHLA and the Rapid Estimate of Adult Literacy in Medicine (REALM) was 0.80, although there were important disagreements between the two tests. The S-TOFHLA is a practical measure of functional health literacy with good reliability and validity that can be used by health educators to identify individuals who require special assistance to achieve learning goals.

The association between age and health literacy among elderly persons.

OBJECTIVE: To examine why older age groups have worse functional health literacy. METHODS: Home interviews were conducted with community-dwelling elderly persons (n = 2,774) to determine demographics, years of school completed, newspaper reading frequency, chronic diseases, and health status. Participants completed the Short Test of Functional Health Literacy in Adults (S-TOFHLA, range 0-100) and the Mini Mental State Examination (MMSE). RESULTS: Mean S-TOFHLA scores declined 1.4 points (95% CI 1.3-1.5) for every year increase in age (p < .001). After adjusting for sex, race, ethnicity, and education, the S-TOFHLA score declined 1.3 points (95% CI 1.2-1.4) for every year increase in age. Even after adjustment for performance on the MMSE, the S-TOFHLA score declined 0.9 points (95% CI 0.8-1.0) for every year increase in age (p < .001). Differences in newspaper reading frequency, visual acuity, chronic medical conditions, and health status, did not explain the lower literacy of older participants. DISCUSSION: Functional health literacy was markedly lower among older age groups even after adjusting for differences in MMSE performance, newspaper reading frequency, health status, and visual acuity. Future studies should prospectively examine whether functional literacy declines with age and whether this is explained by declines in cognitive function.

Economic aspects of the perinatal hospital stay.

This article concentrates on the economics of the perinatal hospital stay for normal vaginal and cesarean section deliveries. Published studies in the United States are reviewed under three headings: inpatient costs for traditional stays, outpatient costs for postpartum services, and costs for short stays with follow-up services. Despite the increasing attention on length of stay after delivery, there has been minimal research examining the true costs of an early discharge program and services compared with longer hospital stays. Formal analysis of alternative strategies and well-designed clinical studies are needed before an optimal policy for caring for mothers and infants can be identified.

Receipt of home health care after early discharge: results from a national managed care organization.

OBJECTIVES: To determine the frequency of home visits during the postpartum period among women discharged within 24 hours after childbirth, to identify characteristics of women who received at least one home visit, and to examine whether a home visit was related to postpartum experiences. METHOD: Women who were enrolled in a Prudential HealthCare plan and had a recent normal vaginal delivery completed a 15-minute telephone survey (N = 5201). Only women who were discharged within 24 hours after delivery were included in this analysis (N = 3121). Selected variables, including maternal characteristics, pregnancy-related and postpartum experiences, and social support factors, were compared for women who received visits and those who did not receive visits within two weeks after delivery. RESULTS: Slightly more than 30% of women participating in the survey received at least one home health care visit within 2 weeks after delivery discharge. Women who received a home visit were more likely to be Black, employed, primaparous, enrolled in a health maintenance organization, or not living in the Southern United States. Compared with women who did not receive a home visit, women who received a visit were more likely to have their newborn receive a phenylketonuria test after discharge, receive a follow-up phone call or housekeeping service, and access to a 24-hour hotline. CONCLUSIONS: Managed care organizations as well as other organized systems of care should be focused on improving the quality of prenatal and postpartum services, and increasing satisfaction of women using these services.

Breast-feeding education and support: association with the decision to breast-feed.

CONTEXT: Rates of breast-feeding in the United States are well below the Healthy People 2000 objective of 75% and do not meet recent American Academy of Pediatrics guidelines. OBJECTIVE: To identify factors associated with the initiation and duration of breast-feeding in managed care enrollees who had had a normal vaginal delivery. DESIGN: Telephone survey of 5213 new mothers (4 to 6 months postpartum) enrolled in commercial managed care plans (response rate 72%). MAIN OUTCOME MEASURES: Starting breast-feeding (ever vs never) and duration of breast-feeding (< or = 6 weeks vs > 6 weeks). ANALYSIS: Logistic regression models controlling for sociodemographic variables. Given the prevalence of the outcome, odds ratios were converted to relative risks (RRs). RESULTS: Seventy-five percent of respondents reported ever breast-feeding, and of those women, 75% reported breast-feeding for more than 6 weeks. In adjusted multivariate analyses, breast-feeding was affected by education, employment, and marital status. Women who were more likely to breast-feed were those who attended childbirth classes (RR, 1.16; 95% CI, 1.11 to 1.20), those who received prenatal breast-feeding advice (RR, 1.24; CI, 1.19 to 1.27), and those who received postpartum breast-feeding assistance (RR, 1.31; CI, 1.15 to 1.34). Breast-feeding for more than 6 weeks postpartum was associated with education, employment status, and the adequacy of postpartum information. CONCLUSIONS: These findings suggest that health plans and employees may promote breast-feeding by providing breast-feeding education and support.

The relationship between characteristics of obstetrician-gynecologists and rates of recommended prenatal care screening tests.

OBJECTIVE: To examine the relationship between characteristics of obstetrician-gynecologists and rates of recommended prenatal care screening tests. DESIGN: Retrospective review of prenatal care records. SETTING: Prudential HealthCare. PARTICIPANTS: Enrolled women (2184) between 14 to 47 years of age who delivered a live birth in 1992, and saw an obstetrics and gynecology (OB/GYN) physician for prenatal care. MAIN OUTCOME MEASURE: Receipt of routine prenatal care screening tests. RESULTS: Pregnant women received most of the recommended prenatal care screening tests more than 90% of the time, with the exception of urinalysis (68.3%), alphafetoprotein (72.1%), glucose challenge (87.5%), and repeat haemoglobin/hematocrit (71.0%). Rates of receiving recommended screening tests varied by obstetrician's gender and number of years since medical school graduation. Women were more likely to receive an antibody test if they saw a female rather than a male obstetrician (p < 0.05), and more likely to receive syphilis serology, rubella, glucose challenge and repeat hemoglobin and/or hematocrit tests if they saw an obstetrician who graduated from medical school within the past 30 years (1965 or later), rather than an obstetrician who graduated more than 30 years ago (p < 0.05). CONCLUSION: The receipt of prenatal care screening tests varies by characteristics of OB/GYN physicians. The results of this study suggest that targeting educational opportunities to OB/GYN physicians whose year of medical school graduation is 1965 or earlier may improve rates of recommended prenatal screening tests.