Secular changes in mortality disparities in New York City: a reexamination.

Previously published analyses showed that inequalities in mortality rates between residents of poor and wealthy neighborhoods in New York City (NYC) narrowed between 1990 and 2000, but these trends may have been influenced by population in-migration and gentrification. The NYC public housing population has been less subject to these population shifts than those in other NYC neighborhoods. We compared changes in mortality rates (MRs) from 1989-1991 to 1999-2001 among residents of NYC census blocks consisting entirely of public housing residences with residents of nonpublic housing low-income and higher-income blocks. Public housing and nonpublic housing low-income blocks were those in census block groups with > or =50% of residents living at <1.5 times the federal poverty level (FPL); nonpublic housing higher-income blocks were those in census block groups with <50% of residents living at <1.5 times the FPL. Information on deaths was obtained from NYC's vital registry, and US Census data were used for denominators. Age-standardized all-cause MRs in public housing, low-income, and higher-income residents decreased between the decades by 16%, 28%, and 22%, respectively. While mortality rate ratios between low-income and higher-income residents narrowed by 8%, the relative disparity between public housing and low-income residents widened by 21%. Diseases amenable to prevention including malignancies, diabetes, and chronic lung disease contributed to the increased overall mortality disparity between public housing and lower-income residents. These findings temper previous findings that inequalities in the health of poor and wealthier NYC neighborhood residents have narrowed. NYC public housing residents should be a high-priority population for efforts to reduce health disparities.

HIV screening among U.S. physicians, 1999-2000.

In 2006, the Centers for Disease Control and Prevention (CDC) put forth recommendations for routine HIV screening for all individuals aged 13-64. The frequency and correlates of HIV screening among U.S. physicians in 2000 were examined to provide baseline data for evaluating the implementation of the 2006 CDC HIV testing guidelines through a survey mailed to a random sample of U.S. physicians in the American Medical Association's Masterfile. The primary outcome was self-reported HIV screening of asymptomatic male and nonpregnant female patients. A total of 4133 (adjusted completion rate of 70.2%) returned a completed survey. Overall, 1133 (28.4%) of physicians reported HIV screening. U.S. physicians, who were female, black, Hispanic, practiced in a city of more than 250,000 people, diagnosed HIV in the past 2 years, or followed up with patients to see if they notified their sexual partners, were more likely to screen their patients for HIV. Emergency medicine, internal medicine, and pediatrics specialists were less likely to screen than family/general practitioners. In 2000, only a quarter of U.S. physicians reported screening their patients for HIV and these rates varied by physician characteristics and practice settings.

Same-sex attraction disclosure to health care providers among New York City men who have sex with men: implications for HIV testing approaches.

BACKGROUND: While the Centers for Disease Control and Prevention recommends at least annual human immunodeficiency virus (HIV) screening for men who have sex with men (MSM), a large number of HIV infections among this population go unrecognized. We examined the association between disclosing to their medical providers (eg, physicians, nurses, physician assistants) same-sex attraction and self-reported HIV testing among MSM in New York City, New York. METHODS: All men recruited from the New York City National HIV Behavioral Surveillance (NHBS) project who reported at least 1 male sex partner in the past year and self-reported as HIV seronegative were included in the analysis. The primary outcome of interest was a participant having told his health care provider that he is attracted to or has sex with other men. Sociodemographic and behavioral factors were examined in relation to disclosure of same-sex attraction. RESULTS: Among the 452 MSM respondents, 175 (39%) did not disclose to their health care providers. Black and Hispanic MSM (adjusted odds ratios, 0.28 [95% confidence interval, 0.14-0.53] and 0.46 [95% confidence interval, 0.24-0.85], respectively) were less likely than white MSM to have disclosed to their health care providers. No MSM who identified themselves as bisexual had disclosed to their health care providers. Those who had ever been tested for HIV were more likely to have disclosed to their health care providers (adjusted odds ratio, 2.10; 95% confidence interval, 1.01-4.38). CONCLUSIONS: These data suggest that risk-based HIV testing, which is contingent on health care providers being aware of their patients' risks, could miss these high-risk persons.

Population vulnerabilities and capacities related to health: a test of a model.

Variability in the health of human populations is greater in economically vulnerable areas. We tested whether this variability reflects and can be explained by: (1) underlying vulnerabilities and capacities of populations and/or (2) differences in the distribution of individual socioeconomic status between populations. Health outcomes were rates of mortality from 12 causes (cardiovascular disease, malignant neoplasms, accidents, chronic lower respiratory disease, cerebrovascular disease, pneumonia and influenza, diseases of the nervous system, suicide, chronic liver disease and cirrhosis, diabetes, homicide, HIV/AIDS) for 59 New York City neighborhoods in 2000. Negative binomial regression models were fit with a measure of socioeconomic vulnerability, median income, predicting each mortality rate. Overdispersion of each model was used to assess whether variability in mortality rates increased with increasing neighborhood socioeconomic vulnerability. To assess the two hypotheses, we examined changes in the variability of mortality rates (as indicated by changes in overdispersion of the models) for outcomes with significant non-constant variability after accounting for (1) vulnerabilities and capacities (social control, quality of local schools, unemployment, low education), and (2) the distribution of individual socioeconomic status (low income, poverty, socioeconomic distribution, high income). Some variability in all mortality rates was explained by accounting for a range of potential vulnerabilities and capacities, supporting the first explanation. However, variability in some causes of mortality was also explained in part by accounting for the distribution of individual resources, supporting the second explanation. The results are consistent with a theory of underlying socioeconomic vulnerabilities of human populations. In areas with lower levels of income, other characteristics of those neighborhoods exacerbate or temper the economic vulnerability, leading to more or less healthy conditions. Understanding the vulnerabilities and capacities that characterize populations may help us better understand the production of population health, and may inform efforts aimed at improving population health.

Neighbourhood mortality inequalities in New York City, 1989-1991 and 1999-2001.

OBJECTIVES: To examine whether inequalities in mortality across socioeconomically diverse neighbourhoods changed alongside the decline in mortality observed in New York City between 1990 and 2000. DESIGN: Cross-sectional analysis of neighbourhood-level vital statistics. SETTING: New York City, 1989-1991 and 1999-2001. MAIN RESULTS: In both poor and wealthy neighbourhoods, age-adjusted mortality for most causes declined between the time periods, although mortality from diabetes increased. Relative inequalities decreased slightly-largely in the under 65 years population-although all-cause rates in 1999-2001 were still 50% higher, and rates of years of potential life lost before age 65 years were 150% higher, in the poorest communities than in the wealthiest ones (relative index of inequality 1.7 and 3.3, respectively). The relative index of inequality for mortality from AIDS increased from 4.7 to 13.9. Over 50% of the excess mortality in the poorest neighbourhoods in 1999-2001 was due to cardiovascular disease, AIDS and cancer. CONCLUSIONS: In New York City, despite substantial declines in absolute mortality and rate differences between poor and wealthy neighbourhoods, great relative socioeconomic inequalities in mortality persist.

Colon cancer screening practices in New York City, 2003: results of a large random-digit dialed telephone survey.

BACKGROUND: New York City (NYC) has one of the highest concentrations of gastroenterologists in the country, yet only 33% of colorectal cancers in NYC are diagnosed early, and approximately 1500 New Yorkers die from colorectal cancer each year. METHODS: Using data from a large, local, random-digit dialed telephone survey (n = 9802), the authors of the current study described types of colorectal cancer screening modalities and characteristics of adults undergoing screening within a recommended timeframe. Multivariate analyses were used to examine demographic, behavioral, socioeconomic, and neighborhood-level predictors of screening participation, with particular attention to factors associated with colonoscopy, the recommended screening modality in NYC. RESULTS: Fifty-five percent of NYC adults aged > or = 50 years reported a recent colorectal cancer screening test, and 42% reported a colonoscopy within the past 10 years. After multiple statistical adjustments, groups with the lowest likelihood of screening were the poor (odds ratio [OR], 0.66; 95% confidence interval [CI], 0.53-0.83) and uninsured (OR, 0.31; 95% CI, 0.20-0.48), as well as Asians (OR, 0.46; 95% CI, 0.29-0. 72), and current smokers (OR, 0.62; 95% CI, 0.50-0.78). Colonoscopy was less frequently reported by non-Hispanic Black New Yorkers and by women; both groups reported higher use of fecal occult blood tests. Less than 10% of adult New Yorkers reported a sigmoidoscopy in the past 5 years. CONCLUSIONS: Low screening uptake in NYC leaves nearly 1 million New Yorkers, particularly poor and uninsured adults, at risk for undetected colorectal cancer. Colonoscopy screening programs in NYC should address health care and socioeconomic barriers and target racial and ethnic minorities and women.