A descriptive study of racial inequalities in mortality from hepatocellular cancer before and after licensure of lifesaving drugs for hepatitis C virus in the United States.

BACKGROUND: Since 1979, mortality from hepatocellular cancer (HCC) has doubled in the United States (US). Lifesaving drugs, prohibitively expensive for some, were approved and marketed to treat hepatitis C virus (HCV), a major risk factor for HCC, beginning in 1997. After the prior introduction of other lifesaving innovations, including active retroviral drug therapy for human immunodeficiency virus and surfactant for respiratory distress syndrome of the newborn, racial inequalities in their mortalities increased in the US. In this descriptive study, we explored racial inequalities in mortality from HCC before and after licensure of HCV drugs in the US. METHODS: The US Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research (WONDER) were used to describe HCC mortality rates from 1979 to 2016 in those 55 years of age and older, because they suffer the largest disease burden. Joinpoint regression was used to analyze trends. To estimate excess deaths, we applied White age-sex-specific rates to corresponding Black populations. FINDINGS: From 1979 to 1998, racial inequalities in mortality from HCC in the US were declining but from 1998 to 2016 racial inequalities steadily increased. From 1998 to 2016, of the 16,770 deaths from HCC among Blacks, the excess relative to Whites increased from 27.8% to 45.4%, and the trends were more prominent in men. Concurrently, racial inequalities in mortality decreased for major risk factors for HCC, including alcohol, obesity and diabetes. INTERPRETATION: These descriptive data, useful to formulate but not test hypotheses, demonstrate decreasing racial inequalities in mortality from HCC which were followed by increases after introduction of lifesaving drugs for HCV in the US. Among many plausible hypotheses generated are social side effects, including unequal accessibility, acceptability and/or utilization. Analytic epidemiological studies designed a priori to do so are necessary to test these and other hypotheses.

Lack of validity of self-reported mammography data.

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Altitude and Variable Effects on Infant Mortality in the United States.

Levine, Robert S., Jason L. Salemi, Maria C. Mejia de Grubb, Sarah K. Wood, Lisa Gittner, Hafiz Khan, Michael A. Langston, Baqar A. Husaini, George Rust, and Charles H. Hennekens. Altitude and variable effects on infant mortality in the United States. High Alt Med Biol. 19:265-271, 2018. AIMS: To explore whether altitude has different effects on infant mortality from newborn respiratory distress, nontraumatic intracranial hemorrhage, and necrotizing enterocolitis. RESULTS: Infants born in the US Mountain Census Division (AR, CO, ID, NV, NM, UT, and WY) had lower mortality from newborn respiratory distress (p < 0.001, mortality rate ratios [MRR] = 0.5 for non-Hispanic blacks and non-Hispanic whites and 0.6 for Hispanic whites) relative to infants born elsewhere in the United States, while Mountain Division non-Hispanic white infants had significantly higher mortality from nontraumatic intracranial hemorrhage (MRR = 1.3 [1.1, 1.6] p < 0.001). After adjustment for state average birth weight, gestational age, and income inequality, a statistically significant, inverse association remained between state average altitude and non-Hispanic white infant mortality from newborn respiratory distress. County altitude (3058 counties in 9 categories from ≤0 to ≥7000 feet) was negatively correlated with newborn respiratory distress (r = -0.91, p < 0.001) and necrotizing enterocolitis (r = -0.81, p = 0.006) at ≤0 to ≥7000 feet and positively correlated with nontraumatic intracranial hemorrhage at ≤0 to 6000-6999 feet (r = 0.78, p = 0.02). CONCLUSIONS: These data show variable cause-specific effects of altitude on infant mortality. Analytic epidemiologic research is needed to confirm or refute the hypotheses generated by these descriptive data.

Depression Effects on Hospital Cost of Heart Failure Patients in California: An Analysis by Ethnicity and Gender.

BACKGROUND: Depression often interferes with self-management and treatment of medical conditions. This may result in serious medical complications and escalated health-care cost. OBJECTIVES: Study distribution of heart failure (HF) cases estimates the prevalence of depression and its effects on HF-related hospital costs by ethnicity and gender. METHODS: Secondary data files of California Hospital Discharge System for he year 2010 were examined. For patients with a HF diagnosis, details regarding depression, demographics, comorbid conditions, and hospital costs were studied. Age-adjusted HF rates and depression were examined for whites, blacks, Hispanics, and Asians/Pacific Islanders (AP) by comparing HF patients with depression (HF+D) versus HF without depression (HFND). RESULTS: HF cases (n = 62,685; average age: 73) included nearly an equal number of males and females. HF rates were higher (P < 0.001) among blacks compared to Hispanics, AP, and whites and higher among males than females. One-fifth of HF patients had depression, higher among females and whites compared to males and other ethnic groups. Further, HF hospital costs for blacks and AP were higher (P < 0.001) compared to other groups. The cost for HF+D was 22% higher compared to HFND, across all gender and ethnic groups, largely due to higher comorbidities, more admissions, and longer hospitalization. CONCLUSION: Depression, ethnicity, and gender are all associated with increased hospital costs of HF patients. The higher HF and HF+D costs among blacks, AP, and males reflect additional burden of comorbidities (hypertension and diabetes). Prospective studies to assess if selective screening and treating depression among HF patients can reduce hospital costs are warranted.

Infant Deaths and Mortality from Gun Violence: Causal or Casual?

OBJECTIVE: Describe trends in non-Hispanic black infant mortality (IM) in the New York City (NYC) counties of Bronx, Kings, Queens, and Manhattan and correlations with gun-related assault mortality. METHODS: Linked Birth/Infant Death data (1999-2013) and Compressed Mortality data at ages 1 to ≥85 years (1999-2013). NYC and United States (US) Census data for income inequality and poverty. Pearson coefficients were used to describe correlations of IM with gun-related assault mortality and other causes of death. RESULTS: In NYC, the risk of non-Hispanic black IM in 2013 was 49% lower than in 1995 (rate ratio: 0.51; 95% CI: 0.43, 0.61). Yearly declines between 1999 and 2013 were significantly correlated with declines in gun-related assault mortality (correlation coefficient (r) = 0.70, p = 0.004), drug-related mortality (r = 0.59, p = 0.020), major heart disease and stroke (r = 0.85, p < 0.001), malignant neoplasms (r = 0.57, p = 0.026), diabetes mellitus (r = 0.63, p = 0.011), and pneumonia and influenza (r = 0.78, p < 0.001). There were no significant correlations of IM with chronic lower respiratory or liver disease, non-drug-related accidental deaths, and non-gun-related assault. Yearly IM (1995-2012) was inversely correlated with income share of the top 1% of the population (r = -0.66, p = 0.007). CONCLUSIONS: In NYC, non-Hispanic black IM declined significantly despite increasing income inequality and was strongly correlated with gun-related assault mortality and other major causes of death. These data are compatible with the hypothesis that activities related to overall population health, including those pertaining to gun-related homicide, may provide clues to reducing IM. Analytic epidemiological studies are needed to test these and other hypotheses formulated from these descriptive data.

Availability of Low-Fat Milk and Produce in Small and Mid-Sized Grocery Stores After 2014 WIC Final Rule Changes, Tennessee.

INTRODUCTION: The 2007 Interim Rule mandated changes to food packages in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) for implementation by 2009. The 2014 Final Rule required additional changes, including increasing the cash value voucher for fruits and vegetables from $6 to $8 for children by June 2014, and allowing only low-fat (1%) or nonfat milk for mothers and children aged 2 to 4 years by October 2014. This study evaluated the effect of the 2014 Final Rule changes on the food environment of small and mid-sized WIC-authorized grocery stores. METHODS: We analyzed secondary data using a natural experimental design to compare the percentage of shelf space for low-fat and nonfat milk and the number of fresh fruit and vegetable varieties in stock before and after the changes. We collected observational data on 18 small and mid-sized WIC-authorized grocery stores in Nashville, Tennessee, using the Nutrition Environment Measures in Store tool in March 2014 and February 2016. RESULTS: The mean percentage of shelf space occupied by low-fat and nonfat milk increased from 2.5% to 14.4% (P = .003), primarily because of an increase in the proportion of low-fat milk (P = .001). The mean number of fresh fruit and vegetable varieties increased from 24.3 to 27.7 (P = .01), with a significant increase for vegetables (P = .008) but not fruit. CONCLUSION: Availability of low-fat milk and variety of fresh vegetables increased after the Final Rule changes in the observed stores. Future research should examine outcomes in other cities.

A Smartphone App for Families With Preschool-Aged Children in a Public Nutrition Program: Prototype Development and Beta-Testing.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the United States provides free supplemental food and nutrition education to low-income mothers and children under age 5 years. Childhood obesity prevalence is higher among preschool children in the WIC program compared to other children, and WIC improves dietary quality among low-income children. The Children Eating Well (CHEW) smartphone app was developed in English and Spanish for WIC-participating families with preschool-aged children as a home-based intervention to reinforce WIC nutrition education and help prevent childhood obesity. OBJECTIVE: This paper describes the development and beta-testing of the CHEW smartphone app. The objective of beta-testing was to test the CHEW app prototype with target users, focusing on usage, usability, and perceived barriers and benefits of the app. METHODS: The goals of the CHEW app were to make the WIC shopping experience easier, maximize WIC benefit redemption, and improve parent snack feeding practices. The CHEW app prototype consisted of WIC Shopping Tools, including a barcode scanner and calculator tools for the cash value voucher for purchasing fruits and vegetables, and nutrition education focused on healthy snacks and beverages, including a Yummy Snack Gallery and Healthy Snacking Tips. Mothers of 63 black and Hispanic WIC-participating children ages 2 to 4 years tested the CHEW app prototype for 3 months and completed follow-up interviews. RESULTS: Study participants testing the app for 3 months used the app on average once a week for approximately 4 and a half minutes per session, although substantial variation was observed. Usage of specific features averaged at 1 to 2 times per month for shopping-related activities and 2 to 4 times per month for the snack gallery. Mothers classified as users rated the app's WIC Shopping Tools relatively high on usability and benefits, although variation in scores and qualitative feedback highlighted several barriers that need to be addressed. The Yummy Snack Gallery and Healthy Snacking Tips scored higher on usability than benefits, suggesting that the nutrition education components may have been appealing but too limited in scope and exposure. Qualitative feedback from mothers classified as non-users pointed to several important barriers that could preclude some WIC participants from using the app at all. CONCLUSIONS: The prototype study successfully demonstrated the feasibility of using the CHEW app prototype with mothers of WIC-enrolled black and Hispanic preschool-aged children, with moderate levels of app usage and moderate to high usability and benefits. Future versions with enhanced shopping tools and expanded nutrition content should be implemented in WIC clinics to evaluate adoption and behavioral outcomes. This study adds to the growing body of research focused on the application of technology-based interventions in the WIC program to promote program retention and childhood obesity prevention.

Heart Failure Hospitalization by Race/Ethnicity, Gender and Age in California: Implications for Prevention.

OBJECTIVE: We examined variation in rates of hospitalization, risk factors, and costs by race/ethnicity, gender and age among heart failure (HF) patients. METHODS: We analyzed California hospital discharge data for patients in 2007 (n=58,544) and 2010 (n=57,219) with a primary diagnosis of HF (ICD-9 codes: 402, 404, 428). HF cases included African Americans (Blacks; 14%), Hispanic/Latinos (21%), and non-Hispanic Whites (65%). Age-adjusted prevalence rates per 100,000 US population were computed per CDC methodology. RESULTS: Four major trends emerged: 1) Overall HF rates declined by 7.7% from 284.7 in 2007 to 262.8 in 2010; despite the decline, the rates for males and Blacks remained higher compared with others in both years; 2) while rates for Blacks (aged ≤54) were 6 times higher compared with same age Whites, rates for Hispanics were higher than Whites in the middle age category; 3) risk factors for HF included hypertension, chronic heart disease, chronic kidney disease, atrial fibrillation, and chronic obstructive pulmonary disease; and 4) submitted hospitalization costs were higher for males, Blacks, and younger patients compared with other groups. CONCLUSIONS: Health inequality in HF persists as hospitalization rates for Blacks remain higher compared with Whites and Hispanics. These findings reinforce the need to determine whether increased access to providers, or implementing proven hypertension and diabetes preventive programs among minorities might reduce subsequent hospitalization for HF in these populations.

Mammography Screening Among the Elderly: A Research Challenge.

BACKGROUND: Randomized trials demonstrate clear benefits of mammography screening in women through age 74 years. We explored age- and race-specific rates of mammography screening and breast cancer mortality among women aged 69 to 84 years. METHODS: We analyzed Medicare claims data for women residing within Surveillance, Epidemiology and End Results geographic areas from 1995 to 2009 from 64,384 non-Hispanic women (4886 black and 59,498 white) and ascertained all primary breast cancer cases diagnosed between ages 69 and 84 years. The exposure was annual or biennial screening mammography during the 4 years immediately preceding diagnosis. The outcome was breast cancer mortality during the 10 years immediately after diagnosis. RESULTS: After adjustment for stage at diagnosis, radiation therapy, chemotherapy, comorbid conditions, and contextual socioeconomic status, hazard ratios (and 95% confidence intervals) for breast cancer mortality relative to no/irregular mammography at 10 years for women aged 69 to 84 years at diagnosis were 0.31 (0.29-0.33) for annual mammography and 0.47 (0.44-0.51) for biennial mammography among whites and 0.36 (0.29-0.44) for annual mammography and 0.47 (0.37-0.58) for biennial mammography among blacks. Trends were similar at 5 years overall and stratified by ages 69 to 74 years, 75 to 78 years, and 79 to 84 years. CONCLUSIONS: In these Medicare claims and Surveillance, Epidemiology and End Results data, elderly non-Hispanic women who self-selected for annual mammography had lower 10-year breast cancer mortality than corresponding women who self-selected for biennial or no/irregular mammography. These findings were similar among black and white women. The data highlight the evidentiary limitations of data used for current screening mammography recommendations.

Use of Six Sigma for eliminating missed opportunities for prevention services.

Delivery of primary care preventative services can be significantly increased utilizing Six Sigma methods. Missed preventative service opportunities were compared in the study clinic with the community clinic in the same practice. The study clinic had 100% preventative services, compared with only 16.3% in the community clinic. Preventative services can be enhanced to Six Sigma quality when the nurse executive and medical staff agree on a single standard of nursing care executed via standing orders.

Social determinants and the classification of disease: descriptive epidemiology of selected socially mediated disease constellations.

BACKGROUND: Most major diseases have important social determinants. In this context, classification of disease based on etiologic or anatomic criteria may be neither mutually exclusive nor optimal. METHODS AND FINDINGS: Units of analysis comprised large metropolitan central and fringe metropolitan counties with reliable mortality rates--(n = 416). Participants included infants and adults ages 25 to 64 years with selected causes of death (1999 to 2006). Exposures included that residential segregation and race-specific social deprivation variables. Main outcome measures were obtained via principal components analyses with an orthogonal rotation to identify a common factor. To discern whether the common factor was socially mediated, negative binomial multiple regression models were developed for which the dependent variable was the common factor. Results showed that infant deaths, mortality from assault, and malignant neoplasm of the trachea, bronchus and lung formed a common factor for race-gender groups (black/white and men/women). Regression analyses showed statistically significant, positive associations between low socio-economic status for all race-gender groups and this common factor. CONCLUSIONS: Between 1999 and 2006, deaths classified as "assault" and "lung cancer", as well as "infant mortality" formed a socially mediated factor detectable in population but not individual data. Despite limitations related to death certificate data, the results contribute important information to the formulation of several hypotheses: (a) disease classifications based on anatomic or etiologic criteria fail to account for social determinants; (b) social forces produce demographically and possibly geographically distinct population-based disease constellations; and (c) the individual components of population-based disease constellations (e.g., lung cancer) are phenotypically comparable from one population to another but genotypically different, in part, because of socially mediated epigenetic variations. Additional research may produce new taxonomies that unify social determinants with anatomic and/or etiologic determinants. This may lead to improved medical management of individuals and populations.

Association of infant feeding with adiposity in early childhood in a WIC sample.

OBJECTIVES: To evaluate the association of different infant feeding practices with adiposity in early childhood. METHODS: Survey was conducted among 150 White, Black, and Hispanic low-income families with children ages 2­4. RESULTS: History of supplementing breast milk with formula (mixed feeding) was more prevalent among Hispanic children (67.4%) than either White (8.5%) or Black children (22.7%) (p<.001). African American children had the highest BMI percentile of the three groups (p=.043), although Hispanic children had slightly higher birth weight than the other two groups (p=.06). Among Hispanic children, after adjusting for confounding variables including maternal BMI, the mixed feeding group and the exclusive formula-feeding group had significantly higher BMI percentile (b=3.068 and b=2.936, respectively) than the exclusive breastfeeding group. These associations were not observed among Blacks and Whites. CONCLUSION: Further research is warranted on the impact of different feeding practices during infancy on subsequent adiposity during pre-school years

Short-term trends in heart failure-related hospitalizations in a high-risk state.

OBJECTIVES: We sought to determine whether there are signs of improvement in the rates of heart failure (HF) hospitalizations given the recent reports of improvement in national trends. METHODS: HF admissions data from the Tennessee Hospital Discharge Data System were analyzed. RESULTS: Hospitalization for primary diagnosis of HF (HFPD) in adults (aged 20 years old or older) decreased from 4.5% in 2006 to 4.2% in 2008. Similarly, age-adjusted HF hospitalization (per 10,000 population) declined by 19.1% (from 45.5 in 2006 to 36.8 in 2008). The age-adjusted rates remain higher among blacks than whites and higher among men than women. Notably, the rate ratio of black-to-white men ages 20 to 34 years admitted with HFPD increased from 8.5 in 2006 to 11.1 in 2008; similarly, the adjusted odds ratios for HFPD were 4.75 (95% confidence interval 3.29-6.86) and 5.61 (95% confidence interval 3.70-8.49), respectively. There was, however, a significant improvement in odds ratio for HF rates among young black women, as evidenced by a decrease from 4.60 to 3.97 (aged 20-34 years) and 4.21 to 3.12 (aged 35-44 years) between 2006 and 2008, respectively. Among patients aged 20 to 34 and 35 to 44 years, hypertension was the strongest independent predictor for HF. Diabetes and myocardial infarction emerged as predictors for HF among patients aged 35 years and older. CONCLUSIONS: The overall rate of HF hospitalization declined during the period surveyed, but the persistent disproportionate involvement of blacks with evidence of worsening among younger black men, requires close attention.

Race, sex, and age differences in heart failure-related hospitalizations in a southern state: implications for prevention.

BACKGROUND: Because heart failure (HF) is the final common pathway for most heart diseases, we examined its 10-year prevalence trend by race, sex, and age in Tennessee. METHODS AND RESULTS: HF hospitalization data from the Tennessee Hospital Discharge Data System were analyzed by race, sex, and age. Rates were directly age-adjusted using the Year 2000 standard population. Adult (age 20+ years) inpatient hospitalization for primary diagnosis of HF (HFPD) increased from 4.2% in 1997 to 4.5% in 2006. Age-adjusted hospitalization for HF (per 10 000 population) rose by 11.3% (from 29.3 in 1997 to 32.6 in 2006). Parallel changes in secondary HF admissions were also noted. Age-adjusted rates were higher among blacks than whites and higher among men than women. The ratios of black to white by sex admitted with HFPD in 2006 were highest (9:1) among the youngest age categories (20 to 34 and 35 to 44 years). Furthermore, for each age category of black men below 65 years, there were higher HF admission rates than for white men in the immediate older age category. In 2006, the adjusted rate ratios for HFPD in black to white men ages 20 to 34 and 35 to 44 years were odds ratio, 4.75; 95% confidence interval, 3.29 to 6.86 and odds ratio, 5.10; 95% confidence interval, 4.15 to 6.25, respectively. Hypertension was the independent predictor of HF admissions in black men ages 20 to 34 years. CONCLUSIONS: The higher occurrence of HF among young adults in general, particularly among young black men, highlights the need for prevention by identifying modifiable biological and social determinants to reduce cardiovascular health disparities in this vulnerable group.

Using a participatory research process to address disproportionate Hispanic cancer burden.

Community-based participatory research (CBPR) offers great potential for increasing the impact of research on reducing cancer health disparities. This article reports how the Community Outreach Core (COC) of the Meharry-Vanderbilt-Tennessee State University (TSU) Cancer Partnership has collaborated with community partners to develop and implement CBPR. The COC, Progreso Community Center, and Nashville Latino Health Coalition jointly developed and conducted the 2007 Hispanic Health in Nashville Survey as a participatory needs assessment to guide planning for subsequent CBPR projects and community health initiatives. Trained community and student interviewers surveyed 500 Hispanic adults in the Nashville area, using a convenience sampling method. In light of the survey results, NLHC decided to focus in the area of cancer on the primary prevention of cervical cancer. The survey led to a subsequent formative CBPR research project to develop an intervention, then to funding of a CBPR pilot intervention study to test the intervention.

Predictors of new screening for African American men participating in a prostate cancer educational program.

BACKGROUND: African American (AA) men continue to have a greater than twofold risk of dying from prostate cancer compared to Whites. METHODS: This community-based intervention study employed a quasi-experimental, delayed-control (cross-over) design with randomization at the church-level (N = 345 AA men). RESULTS: Logistic regression analyses revealed that the level of knowledge (b = .61, P < .05, Exp (B) = 1.84), the perception of risk (b = 2.99, P < .01, Exp (B) = 19.95), and having insurance (b = 3.20, P < .01, Exp (B) = 24.65) significantly increased the odds of participants who needed screening getting screened during study. DISCUSSION: This study demonstrated the need for education, community involvement, and increased access to encourage minority men to obtain needed health screenings.

A church-based program on prostate cancer screening for African American men: reducing health disparities.

INTRODUCTION: African American men have a significantly higher incidence of prostate cancer, are diagnosed at younger ages and more advanced stages, and have higher mortality rates from prostate cancer than do White men. METHODS: This community-based intervention study employed a quasiexperimental delayed-control (crossover) design with randomization at the church level. Forty-five African American churches were randomly assigned to two study groups: early intervention and delayed intervention. A convenience sample of 430 African American male volunteers (ages 40-70) was enrolled through the churches, and 350 men remained in the study through wave 3. The intervention was a culturally tailored group educational program, which included a video and a question-and-answer session with an African American physician. RESULTS: Within each group, knowledge, perceived threat, and screening prevalence all increased significantly. However, the magnitude of increases was similar, so the groups did not differ significantly at wave 2. Knowledge at wave 2 was associated with greater odds of having a digital rectal exam by wave 3 only for the early-intervention group. The early-intervention group was two times more likely to have talked to a physician about prostate cancer screening by wave 3. CONCLUSIONS: The findings suggest that the delayed-intervention group did not function as a pure control and may have unintentionally received a partial intervention. This finding demonstrated that a low-cost prostate cancer awareness campaign within a church may be enough to affect prostate cancer knowledge, attitudes, and behaviors among African American men. Further research should examine the church-specific intervention elements, cultural appropriateness of the messages, and whether group sessions provide additional effect.

Black-white disparities in elderly breast cancer mortality before and after implementation of Medicare benefits for screening mammography.

BACKGROUND: Medicare implemented reimbursement for screening mammography in 1991. MAIN FINDINGS: Post-implementation, breast cancer mortality declined faster (p< .0001) among White than among Black elderly women (65+ years). No excess breast cancer deaths occurred among Black elderly compared with White elderly through 1990; over 2,459 have occurred since. Contextual socioeconomic status does not explain differences between counties with lowest Black breast cancer mortality/post-implementation declines in disparity and counties with highest Black breast cancer mortality/widened disparity post-implementation. CONCLUSIONS: The results lead to these hypotheses: (a) Medicare mammography reimbursement was causally associated with declines in elderly mortality and widened elderly Black:White disparity from breast cancer; (b) the latter reflects inherent Black-White differences in risk of breast cancer death; place-specific, unaddressed inequalities in capacity to use Medicare benefits; and/or other factors; (c) previous observations linking poverty with disparities in breast cancer mortality are partly confounded by factors explained by theories of human capability and diffusion of innovation.

EPSDT preventive services in a low-income pediatric population: impact of a nursing protocol.

Medicaid mandates coverage of clinical preventive services for children under the Early and Periodic Screening, Diagnosis, and Treatment program (EPSDT). This article assesses the usefulness of a nursing protocol for delivering comprehensive EPSDT services to pediatric patients during any primary care visit. Secondary data from a recent controlled trial were analyzed. An intervention group received the clinical protocol (n = 514 children in a low-income pediatric clinic), whereas data from a "usual care" comparison group were obtained from medical records (n = 115 children). The nursing protocol included 52 items corresponding to EPSDT services and was administered by a prevention nurse. In the intervention group, 11 605 out of 11 607 (approximately 100.0%) EPSDT service needs were initiated, as compared to 21.2% (572 out of 2695) in the comparison group (P < .001). The study demonstrates the feasibility of using a nursing protocol to integrate EPSDT clinical preventive services into pediatric visits.

Black-White mortality from HIV in the United States before and after introduction of highly active antiretroviral therapy in 1996.

OBJECTIVES: We sought to describe Black-White differences in HIV disease mortality before and after the introduction of highly active antiretroviral treatment (HAART). METHODS: Black-White mortality from HIV is described for the nation as a whole. We performed regression analyses to predict county-level mortality for Black men aged 25-84 years and the corresponding Black:White male mortality ratios (disparities) in 140 counties with reliable Black mortality for 1999-2002. RESULTS: National Black-White disparities widened significantly after the introduction of HAART, especially among women and the elderly. In county regression analyses, contextual socioeconomic status (SES) was not a significant predictor of Black:White mortality rate ratio after we controlled for percentage of the population who were Black and percentage of the population who were Hispanic, and neither contextual SES nor race/ethnicity were significant predictors after we controlled for pre-HAART mortality. Contextual SES, race, and pre-HAART mortality were all significant and independent predictors of mortality among Black men. CONCLUSIONS: Although nearly all segments of the Black population experienced widened post-HAART disparities, disparities were not inevitable and tended to reflect pre-HAART levels. Public health policymakers should consider the hypothesis of unequal diffusion of the HAART innovation, with place effects rendering some communities more vulnerable than others to this potential problem.