Sexual Orientation Disparities in Risk Factors for Adverse COVID-19-Related Outcomes, by Race/Ethnicity - Behavioral Risk Factor Surveillance System, United States, 2017-2019.

Sexual minority persons experience health disparities associated with sexual stigma and discrimination and have a high prevalence of several health conditions that have been associated with severe coronavirus disease 2019 (COVID-19) (1,2). Current COVID-19 surveillance systems do not capture information about sexual orientation. To begin bridging the gap in knowledge about COVID-19 risk among sexual minority adults, CDC examined disparities between sexual minority and heterosexual adults in the prevalence of underlying conditions with strong or mixed evidence of associations with severe COVID-19-related illness (3), by using data from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS).* When age, sex, and survey year are adjusted, sexual minority persons have higher prevalences than do heterosexual persons of self-reported cancer, kidney disease, chronic obstructive pulmonary disease (COPD), heart disease (including myocardial infarction, angina, or coronary heart disease), obesity, smoking, diabetes, asthma, hypertension, and stroke. Sexual minority adults who are members of racial/ethnic minority groups disproportionately affected by the pandemic also have higher prevalences of several of these health conditions than do racial/ethnic minority adults who are heterosexual. Collecting data on sexual orientation in COVID-19 surveillance and other studies would improve knowledge about disparities in infection and adverse outcomes by sexual orientation, thereby informing more equitable responses to the pandemic.

Effects of Hurricanes on Emergency Department Utilization: An Analysis Across 7 US Storms.

OBJECTIVE: Emergency departments (EDs) are critical sources of care after natural disasters such as hurricanes. Understanding the impact on ED utilization by subpopulation and proximity to the hurricane's path can inform emergency preparedness planning. This study examines changes in ED utilization for residents of 344 counties after the occurrence of 7 US hurricanes between 2005 and 2016. METHODS: This retrospective observational study used ED data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases. ED utilization rates for weeks during and after hurricanes were compared with pre-hurricane rates, stratified by the proximity of the patient county to the hurricane path, age, and disease category. RESULTS: The overall population rate of weekly ED visits changed little post-hurricane, but rates by disease categories and age demonstrated varying results. Utilization rates for respiratory disorders exhibited the largest post-hurricane increase, particularly 2-3 weeks following the hurricane. The change in population rates by disease categories and age tended to be larger for people residing in counties closer to the hurricane path. CONCLUSIONS: Changes in ED utilization following hurricanes depend on disease categories, age, and proximity to the hurricane path. Emergency managers could incorporate these factors into their planning processes.

Explaining Disparities in Severe Headache and Migraine Among Sexual Minority Adults in the United States, 2013-2018.

Previous work has not examined how the association of sexual orientation and severe headache/migraine may be explained by differences between sexual minorities and heterosexuals in sociodemographic and health-related characteristics. Using data from the 2013-2018 National Health Interview Survey, regression decomposition was used to identify determinants of disparities in headache/migraine between sexual minorities collectively and heterosexuals, as well as between bisexual men and gay men, and bisexual women and lesbians. The prevalence of headache/migraine was the highest among bisexual women (36.8%), followed by lesbians (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%). Across all models, the largest percentage of the disparity between sexual orientation/gender groups was attributable to age (range, 18.3%-42.2%), serious psychological distress (range, 6.6%-14.0%), and hours of regular sleep (range, 1.7%-8.2%). Although age accounted for the largest part of the disparity in headache/migraine by sexual orientation, several modifiable risk factors also played a role.

State variation in opioid treatment policies and opioid-related hospital readmissions.

BACKGROUND: State policy approaches designed to provide opioid treatment options have received significant attention in addressing the opioid epidemic in the United States. In particular, expanded availability of naloxone to reverse overdose, Good Samaritan laws intended to protect individuals who attempt to provide or obtain emergency services for someone experiencing an opioid overdose, and expanded coverage of medication-assisted treatment (MAT) for individuals with opioid abuse or dependence may help curtail hospital readmissions from opioids. The objective of this retrospective cohort study was to evaluate the association between the presence of state opioid treatment policies-naloxone standing orders, Good Samaritan laws, and Medicaid medication-assisted treatment (MAT) coverage-and opioid-related hospital readmissions. METHODS: We used 2013-2015 hospital inpatient discharge data from 13 states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. We examined the relationship between state opioid treatment policies and 90-day opioid-related readmissions after a stay involving an opioid diagnosis. RESULTS: Our sample included 383,334 opioid-related index hospitalizations. Patients treated in states with naloxone standing-order policies at the time of the index stay had higher adjusted odds of an opioid-related readmission than did those treated in states without such policies; however, this relationship was not present in states with Good Samaritan laws. Medicaid methadone coverage was associated with higher odds of readmission among all insurance groups except Medicaid. Medicaid MAT coverage generosity was associated with higher odds of readmission among the Medicaid group but lower odds of readmission among the Medicare and privately insured groups. More comprehensive Medicaid coverage of substance use disorder treatment and a greater number of opioid treatment programs were associated with lower odds of readmission. CONCLUSIONS: Differences in index hospitalization rates suggest that states with opioid treatment policies had a higher level of need for opioid-related intervention, which also may account for higher rates of readmission. More research is needed to understand how these policies can be most effective in influencing acute care use.

Annual Report on Health Care for Children and Youth in the United States: Focus on 30-Day Unplanned Inpatient Readmissions, 2009 to 2014.

OBJECTIVE: To describe trends in unplanned 30-day all-condition hospital readmissions for children aged 1 to 17 years between 2009 and 2014. METHODS: Analysis was conducted with the 2009-14 Nationwide Readmissions Database from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project. Annual hospital readmission rates, resource use, and the most common reasons for readmission were calculated for the 2009-14 period. RESULTS: The rate of readmission for children aged 1 to 17 years was essentially stable between 2009 and 2014 (5.5% in 2009 and 5.9% in 2014). In 2009, the most common reason (principal diagnosis) for readmission was sickle cell anemia, whereas in 2014 the most common reason was epilepsy. Pneumonia fell from the second to the sixth most common reason for readmission over this period (from 3832 to 2418 stays). Other respiratory infections were among the top 10 principal readmission diagnoses in 2009, but not in 2014. Septicemia was among the 10 most common reasons for readmission in 2014, but not in 2009. Although the average cost of index (ie, initial) stays with a subsequent readmission were similar in 2009 and 2014, the average cost of index stays without a readmission and cost of readmission stays increased by approximately 23%. In both 2009 and 2014, the average cost of the index stays with a subsequent readmission was 73% to 89% higher than that of the index stays of children who were not readmitted within 30 days. The average cost of index stays preceding a readmission was 33% to 45% higher than average costs for readmitted stays. In 2014, the aggregate cost of index stays plus readmissions was $1.58 billion, with 42.9% of the costs attributable to readmissions. Regarding the average costs and lengths of stay for the 10 most common readmission diagnoses, in 2009 the average cost per stay for complications of devices, implants, or grafts was nearly 5 times greater than that of asthma ($21,200 vs $4500, respectively). In 2014, average cost per stay ranged from $5500 for asthma to $39,500 for septicemia. In 2009, the average length of stay (LOS) for complications of devices, implants, or grafts was more than 3 three times higher than that for asthma (7.8 days vs 2.5 days, respectively), and in 2014, the average LOS for septicemia was nearly 4 times higher than that for asthma (10.4 days vs. 2.6 days). CONCLUSIONS: This study provides a baseline assessment for examining trends in 30-day unplanned pediatric readmissions, an important quality metric as the provisions of the Children's Health Insurance Program Reauthorization Act and the Affordable Care Act are changed and implemented in the future. More than 50,000 pediatric hospital stays in 2014 occurred within 30 days of a previous hospitalization, with an average cost of $13,800. This report is timely, as the health care system works to become more patient-centered and public and private payers grapple with how to pay for quality care for children. The report provides baseline information that can be used to further explore ways to reduce unplanned readmissions.

Racial Disparities in Sepsis-Related In-Hospital Mortality: Using a Broad Case Capture Method and Multivariate Controls for Clinical and Hospital Variables, 2004-2013.

OBJECTIVES: As sepsis hospitalizations have increased, in-hospital sepsis deaths have declined. However, reported rates may remain higher among racial/ethnic minorities. Most previous studies have adjusted primarily for age and sex. The effect of other patient and hospital characteristics on disparities in sepsis mortality is not yet well-known. Furthermore, coding practices in claims data may influence findings. The objective of this study was to use a broad method of capturing sepsis cases to estimate 2004-2013 trends in risk-adjusted in-hospital sepsis mortality rates by race/ethnicity to inform efforts to reduce disparities in sepsis deaths. DESIGN: Retrospective, repeated cross-sectional study. SETTING: Acute care hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases for 18 states with consistent race/ethnicity reporting. PATIENTS: Patients diagnosed with septicemia, sepsis, organ dysfunction plus infection, severe sepsis, or septic shock. MEASUREMENTS AND MAIN RESULTS: In-hospital sepsis mortality rates adjusted for patient and hospital factors by race/ethnicity were calculated. From 2004 to 2013, sepsis hospitalizations for all racial/ethnic groups increased, and mortality rates decreased by 5-7% annually. Mortality rates adjusted for patient characteristics were higher for all minority groups than for white patients. After adjusting for hospital characteristics, sepsis mortality rates in 2013 were similar for white (92.0 per 1,000 sepsis hospitalizations), black (94.0), and Hispanic (93.5) patients but remained elevated for Asian/Pacific Islander (106.4) and "other" (104.7; p < 0.001) racial/ethnic patients. CONCLUSIONS: Our results indicate that hospital characteristics contribute to higher rates of sepsis mortality for blacks and Hispanics. These findings underscore the importance of ensuring that improved sepsis identification and management is implemented across all hospitals, especially those serving diverse populations.

Differences in Use of High-quality and Low-quality Hospitals Among Working-age Individuals by Insurance Type.

BACKGROUND: Research suggests that individuals with Medicaid or no insurance receive fewer evidence-based treatments and have worse outcomes than those with private insurance for a broad range of conditions. These differences may be due to patients' receiving care in hospitals of different quality. RESEARCH DESIGN: We used the Healthcare Cost and Utilization Project State Inpatient Databases 2009-2010 data to identify patients aged 18-64 years with private insurance, Medicaid, or no insurance who were hospitalized with acute myocardial infarction, heart failure, pneumonia, stroke, or gastrointestinal hemorrhage. Multinomial logit regressions estimated the probability of admissions to hospitals classified as high, medium, or low quality on the basis of risk-adjusted, in-hospital mortality. RESULTS: Compared with patients who have private insurance, those with Medicaid or no insurance were more likely to be minorities and to reside in areas with low-socioeconomic status. The probability of admission to high-quality hospitals was similar for patients with Medicaid (23.3%) and private insurance (23.0%) but was significantly lower for patients without insurance (19.8%, P<0.01) compared with the other 2 insurance groups. Accounting for demographic, socioeconomic, and clinical characteristics did not influence the results. CONCLUSIONS: Previously noted disparities in hospital quality of care for Medicaid recipients are not explained by differences in the quality of hospitals they use. Patients without insurance have lower use of high-quality hospitals, a finding that needs exploration with data after 2013 in light of the Affordable Care Act, which is designed to improve access to medical care for patients without insurance.

Identifying in-patient costs attributable to the clinical sequelae and comorbidities of alcoholic liver disease in a national hospital database.

BACKGROUND AND AIMS: The clinical sequelae and comorbidities of alcoholic liver disease (ALD) often require hospitalization. The aims of this study were to (1) compare the average costs of hospitalizations with ALD and the costs of hospitalizations with other alcohol-related diagnoses that do not involve the liver; and (2) estimate the percentage of the difference in costs between the ALD and non-ALD hospitalizations that may be attributed to ascites, protein-calorie malnutrition and other conditions. DESIGN: The 2012 National Inpatient Sample is a population-based cross-sectional database representing more than 94% of all discharges from community hospitals in the United States. SETTING: Community hospitals in the United States. PARTICIPANTS: The sample included 72 531 hospitalizations with ALD and 287 047 hospitalizations with other alcohol-related diagnoses. MEASUREMENTS: The dependent variable was total in-patient costs. We estimated the contribution of ascites, protein-calorie malnutrition and other conditions to the difference in costs between patients with ALD and patients with other diagnoses. FINDINGS: Average costs for ALD patients were $3188.4 higher than those for patients with other diagnoses ($13 543 versus $10 355; P < 0.001). Among all conditions in the analysis, protein-calorie malnutrition had the largest impact on costs [$6501; 95% confidence interval (CI) = 5956, 7045; P < 0.001] accounting for 12% of the higher costs of ALD stays. CONCLUSIONS: Costs of hospital care for patients with alcoholic liver disease are higher than those for patients with other alcohol-related diagnoses. These increased costs are associated with specific clinical sequelae and comorbidities, with protein-calorie malnutrition-a largely preventable condition-making a substantial contribution.

Age-related Disparities in Trauma Center Access for Severe Head Injuries Following the Release of the Updated Field Triage Guidelines.

OBJECTIVE: In 2006, the American College of Surgeons' Committee on Trauma and the Centers for Disease Control and Prevention released field triage guidelines with special consideration for older adults. Additional considerations for direct transport to a Level I or II trauma center (TC) were added in 2011, reflecting perceived undertriage to TCs for older adults. We examined whether age-based disparities in TC care for severe head injury decreased following introduction of the 2011 revisions. METHODS: A pre-post design analyzing the 2009 and 2012 Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases with multivariable logistic regressions considered changes in 1) the trauma designation of the emergency department where treatment was initiated and 2) transfer to a TC following initial treatment at a non-TC. RESULTS: Compared with adults aged 18 to 44 years, after multivariable adjustment, in both years TC care was less likely for adults aged 45 to 64 years (odds ratio [OR] = 0.76 in 2009 and 0.74 in 2012), aged 65 to 84 years (OR = 0.61 and 0.59), and aged 85+ years (OR = 0.53 and 0.56). Between 2009 and 2012, the likelihood of TC care increased for all age groups, with the largest increase among those aged 85+ years (OR = 1.18), which was statistically different (p = 0.02) from the increase among adults aged 18 to 44 years (OR = 1.12). The analysis of transfers yielded similar results. CONCLUSIONS: Although patterns of increased TC treatment for all groups with severe head trauma indicate improvements, age-based disparities persisted.

Personal and professional challenges confronted by hospital staff following hurricane sandy: a qualitative assessment of management perspectives.

BACKGROUND: Adequate hospital staffing during and after a disaster is critical to meet increased health care demands and to ensure continuity of care and patient safety. However, when a disaster occurs, staff may become both victim and responder, decreasing their ability and willingness to report for work. This qualitative study assessed the personal and professional challenges that affected staff decisions to report to work following a natural disaster and examined the role of management in addressing staff needs and concerns. METHODS: Semi-structured interviews were conducted with individuals who filled key management roles in the United States Department of Veterans Affairs New York Harbor Healthcare System's response to Superstorm Sandy and during the facility's initial recovery phase. All interviews were audio recorded and transcribed. Three major themes were identified: 1) Barriers to reporting ("Barriers"), 2) Facilitators to reporting ("Facilitators"), and 3) Responses to staff needs and concerns ("Responses"). Atlas.ti 7.1.6 software program was used for the management and analysis of the transcripts. RESULTS: Results indicated that staff encountered several barriers that impeded their ability to report to work at mobile vans at the temporarily nonoperational Manhattan campus or at two other VA facilities in Brooklyn and the Bronx in the initial post-Sandy period including transportation problems, personal property damage, and communication issues. In addition, we found evidence of facilitators to reporting as expressed through descriptions of professional duty. Our findings also revealed that management was aware of the challenges that staff was facing and made efforts to reduce barriers and accommodate staff affected by the storm. CONCLUSIONS: During and after a disaster event, hospital staff is often confronted with challenges that affect decisions to report for work and perform effectively under potentially harsh conditions. This study examined barriers and facilitators that hospital staff encountered following a major natural disaster from the management perspective. Insights gained from this study can be used to inform future disaster planning and preparedness efforts, and help ensure that there is adequate staffing to mount an effective response when a disaster occurs, and to recover from its aftermath.

The effects of multiple chronic conditions on hospitalization costs and utilization for ambulatory care sensitive conditions in the United States: a nationally representative cross-sectional study.

BACKGROUND: The presence of multiple chronic conditions (MCCs) complicates inpatient hospital care, leading to higher costs and utilization. Multimorbidity also complicates primary care, increasing the likelihood of hospitalization for ambulatory care sensitive conditions. The purpose of this study was to evaluate how MCCs relate to inpatient hospitalization costs and utilization for ambulatory care sensitive conditions. METHODS: The 2012 Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) provided data to carry out a cross-sectional analysis of 1.43 million claims related to potentially preventable hospitalizations classified by the AHRQ Prevention Quality Indicator (PQI) composites. Categories of MCCs (0-1, 2-3, 4-5, and 6+) were examined in sets of acute, chronic, and overall PQIs. Multivariate models determined associations between categories of MCCs and 1) inpatient costs per stay, 2) inpatient costs per day, and 3) length of inpatient hospitalization. Negative binomial was used to model costs per stay and costs per day. RESULTS: The most common category observed was 2 or 3 chronic conditions (37.8 % of patients), followed by 4 or 5 chronic conditions (30.1 % of patients) and by 6+ chronic conditions (10.1 %). Compared with costs for patients with 0 or 1 chronic condition, hospitalization costs per stay for overall ambulatory care sensitive conditions were 19 % higher for those with 2 or 3 (95 % confidence interval [CI] 1.19-1.20), 32 % higher for those with 4 or 5 (95 % CI 1.31-1.32), and 31 % higher (95 % CI 1.30-3.32) for those with 6+ conditions. Acute condition stays were 11 % longer when 2 or 3 chronic conditions were present (95 % CI 1.11-1.12), 21 % longer when 4 or 5 were present (95 % CI 1.20-1.22), and 27 % longer when 6+ were present (95 % CI 1.26-1.28) compared with those with 0 or 1 chronic condition. Similar results were seen within chronic conditions. Associations between MCCs and total costs were driven by longer stays among those with more chronic conditions rather than by higher costs per day. CONCLUSIONS: The presence of MCCs increased inpatient costs for ambulatory care sensitive conditions via longer hospital stays.

Personal medication preparedness among veteran and nonveteran men and women in the California population.

INTRODUCTION: The health of people with chronic medical conditions is particularly vulnerable to the disruptions caused by public health disasters, especially when there is massive damage to the medical infrastructure. Government agencies and national organizations recommend that people with chronic illness prepare for disasters by stockpiling extra supplies of medications. PROBLEM: A wide range of chronic illnesses has long been documented among veterans of the US armed forces. Veterans with chronic illness could be at great risk of complications due to disaster-related medication disruptions; however, the prevalence of personal medication preparedness among chronically ill veterans is not currently known. METHODS: Data was used from the 2009 California Health Interview Survey on 28,167 respondents who reported taking daily medications. After adjusting for differences in age, health status, and other characteristics, calculations were made of the percentage of respondents who had a two-week supply of emergency medications and, among respondents without a supply, the percentage who said they could obtain one. Veteran men, veteran women, nonveteran men, and nonveteran women were compared. RESULTS: Medication supplies among veteran men (81.9%) were higher than among nonveteran women (74.8%; P < .0001) and veteran women (81.1%; P = 0.014). Among respondents without medication supplies, 67.2% of nonveteran men said that they could obtain a two-week supply, compared with 60.1% of nonveteran women (P = .012). Discussion Among adults in California with chronic illness, veteran men are more likely to have personal emergency medication supplies than are veteran and nonveteran women. Veteran men may be more likely to be prepared because of their training to work in combat zones and other emergency situations, which perhaps engenders in them a culture of preparedness or self-reliance. It is also possible that people who choose to enlist in the military are different from the general population in ways that make them more likely to be better prepared for emergencies. CONCLUSION: Veterans in California have a relatively high level of emergency medication preparedness. Given the health complications that can result from disaster-related medication disruptions, this is a promising finding. Disasters are a national concern, however, and the personal preparedness of veterans in all parts of the nation should be assessed; these findings could serve as a useful reference point for such work in the future.

Confidence in the fairness of local public health systems' response to disasters: the US Veterans' perspective.

OBJECTIVE: The effectiveness of local public health systems in emergency management depends on trust from the entire community. However, the failure of some government agencies to respond effectively to several major disasters has had a disproportionate impact on certain groups-racial/ethnic minorities, in particular-that are well-represented in the veteran population. Many veterans belong to multiple vulnerable populations at greater risk of harm during disasters. This study examines confidence that local public health systems will respond fairly to disasters in a diverse sample of US veterans. METHODS: This study is an analysis of cross-sectional data on 5955 veterans in the 2009 California Health Interview Survey. Respondents were asked about their confidence that public health systems would respond fairly to their needs in the event of a disaster, regardless of their race/ethnicity or other personal characteristics. Multivariable regression analysis was used to identify variables on respondent characteristics that were independently associated with confidence. The hypothesis was that there would be less confidence in county public health systems among respondents who were racial/ethnic minorities, had less than a college degree, and were of low-income backgrounds. RESULTS: Approximately 79% of veterans were confident that public health systems would respond fairly. The hypothesis was unsupported, with no differences in confidence by race/ethnicity, education, or income. Also, no differences were noted between men and women or between veterans with and without disabilities. However, confidence was associated with continent of birth, age, homeownership, and marital status. CONCLUSION: If confidence affects veterans' willingness to accept disaster preparedness communications or to give proper consideration to recommended emergency countermeasures, then local health departments that issue such information to veterans are not likely to encounter barriers by race/ethnicity, income, education, disability status, or gender.

Partnering to harmonize IRBs for community-engaged research to reduce health disparities.

Emerging advances in health disparities research include controlled trials and comparative effectiveness studies that are frequently conducted at multiple community and academic sites. Review by different institutional review boards (IRBs) presents a major impediment to the timely and effective conduct of such research. When research involves minority and underserved communities as well as multiple geographic regions, institutional requirements and interpretation of ethical standards may vary substantially. Such variations can complicate the informed consent process and research protocol, and may undermine participant respect and trial quality. In addition, multiple IRB review can lead to unnecessary delays, jeopardizing funding and capacity to perform collaborative projects. In response to these issues, the Research Centers in Minority Institutions (RCMI) Translational Research Network (RTRN) is developing a community-partnered approach to streamlining IRB review across its consortium of 18 RCMI grantee institutions that will ensure compliance while enhancing the quality of health disparities research.

A comparison of item response theory-based methods for examining differential item functioning in object naming test by language of assessment among older Latinos.

Object naming tests are commonly included in neuropsychological test batteries. Differential item functioning (DIF) in these tests due to cultural and language differences may compromise the validity of cognitive measures in diverse populations. We evaluated 26 object naming items for DIF due to Spanish and English language translations among Latinos (n=1,159), mean age of 70.5 years old (Standard Deviation (SD)±7.2), using the following four item response theory-based approaches: Mplus/Multiple Indicator, Multiple Causes (Mplus/MIMIC; Muthén & Muthén, 1998-2011), Item Response Theory Likelihood Ratio Differential Item Functioning (IRTLRDIF/MULTILOG; Thissen, 1991, 2001), difwithpar/Parscale (Crane, Gibbons, Jolley, & van Belle, 2006; Muraki & Bock, 2003), and Differential Functioning of Items and Tests/MULTILOG (DFIT/MULTILOG; Flowers, Oshima, & Raju, 1999; Thissen, 1991). Overall, there was moderate to near perfect agreement across methods. Fourteen items were found to exhibit DIF and 5 items observed consistently across all methods, which were more likely to be answered correctly by individuals tested in Spanish after controlling for overall ability.

The effect of urban street gang densities on small area homicide incidence in a large metropolitan county, 1994-2002.

The presence of street gangs has been hypothesized as influencing overall levels of violence in urban communities through a process of gun-drug diffusion and cross-type homicide. This effect is said to act independently of other known correlates of violence, i.e., neighborhood poverty. To test this hypothesis, we independently assessed the impact of population exposure to local street gang densities on 8-year homicide rates in small areas of Los Angeles County, California. Homicide data from the Los Angeles County Coroners Office were analyzed with original field survey data on street gang locations, while controlling for the established covariates of community homicide rates. Bivariate and multivariate regression analyses explicated strong relationships between homicide rates, gang density, race/ethnicity, and socioeconomic structure. Street gang densities alone had cumulative effects on small area homicide rates. Local gang densities, along with high school dropout rates, high unemployment rates, racial and ethnic concentration, and higher population densities, together explained 90% of the variation in local 8-year homicide rates. Several other commonly considered covariates were insignificant in the model. Urban environments with higher densities of street gangs exhibited higher overall homicide rates, independent of other community covariates of homicide. The unique nature of street gang killings and their greater potential to influence future local rates of violence suggests that more direct public health interventions are needed alongside traditional criminal justice mechanisms to combat urban violence and homicides.

The role of medical education in reducing health care disparities: the first ten years of the UCLA/Drew Medical Education Program.

BACKGROUND: The University of California, Los Angeles (UCLA)/Charles R. Drew University Medical Education Program was developed to train physicians for practice in underserved areas. The UCLA/Drew Medical Education Program students receive basic science instruction at UCLA and complete their required clinical rotations in South Los Angeles, an impoverished urban community. We have previously shown that, in comparison to their UCLA counterparts, students in the Drew program had greater odds of maintaining their commitment to medically disadvantaged populations over the course of medical education. OBJECTIVE: To examine the independent association of graduation from the UCLA/Drew program with subsequent choice of physician practice location. We hypothesized that participation in the UCLA/Drew program predicts future practice in medically disadvantaged areas, controlling for student demographics such as race/ethnicity and gender, indicators of socioeconomic status, and specialty choice. DESIGN: Retrospective cohort study. PARTICIPANTS: Graduates (1,071) of the UCLA School of Medicine and the UCLA/Drew Medical Education Program from 1985-1995, practicing in California in 2003 based on the address listed in the American Medical Association (AMA) Physician Masterfile. MEASUREMENTS: Physician address was geocoded to a California Medical Service Study Area (MSSA). A medically disadvantaged community was defined as meeting any one of the following criteria: (a) federally designated HPSA or MUA; (b) rural area; (c) high minority area; or (d) high poverty area. RESULTS: Fifty-three percent of UCLA/Drew graduates are located in medically disadvantaged areas, in contrast to 26.1% of UCLA graduates. In multivariate analyses, underrepresented minority race/ethnicity (OR: 1.57; 95% CI: 1.10-2.25) and participation in the Drew program (OR: 2.47; 95% CI: 1.59-3.83) were independent predictors of future practice in disadvantaged areas. CONCLUSIONS: Physicians who graduated from the UCLA/Drew Medical Education Program have higher odds of practicing in underserved areas than those who completed the traditional UCLA curriculum, even after controlling for other factors such as race/ethnicity. The association between participation in the UCLA/Drew Medical Education Program and physician practice location suggests that medical education programs may reinforce student goals to practice in disadvantaged communities.

Community characteristics and violence against homeless women in Los Angeles County.

Research on violence against homeless women has focused mainly on individual rather than community-level risk factors. Using an ecological conceptual framework, we estimated the independent association of community characteristics with sexual and physical assault in a probability sample of 974 homeless women. Participants were interviewed at 66 assistance programs in Los Angeles County, California in 1997. Individual responses were linked to community-level data from land use files and the U.S. Census by the facility ZIP codes. Multivariate logistic regression analysis showed that women using service providers in closer proximity to Skid Row had higher odds of physical assault (OR=1.48; 95% CI=1.03, 2.14). A number of individual characteristics were also associated with violent victimization. To reduce violence against homeless women, ensuring the safety of locations for shelters and other assistance programs should be a planning priority for local housing authorities.

Racial and ethnic differences in unmet need for vision care among children with special health care needs.

OBJECTIVE: To examine racial and ethnic differences in unmet need for vision care among children with special health care needs. METHODS: Cross-sectional data from the National Survey of Children with Special Health Care Needs were analyzed. The analytic sample was 14,070 children with special health care needs who needed eyeglasses or vision care in the previous year. Children who did not receive all the eyeglasses or vision care they needed were considered to have unmet need for vision care. RESULTS: Of the sample, 5.8%, representing approximately 198,600 children with special health care needs in the United States, had unmet need for vision care. Rates of unmet need ranged from 2.5% to 14.3% across the 7 racial and ethnic groups studied. Relative to whites, children of African American, Latino, and multiracial backgrounds had approximately twice the adjusted risk of unmet need, whereas American Indian or Alaskan Native children had a lower adjusted risk. Health care providers, school personnel, insurance coverage, and other factors also contributed to differences in the risk of unmet need, independently of child race/ethnicity. CONCLUSION: Further research is needed to explain and address the causes of racial and ethnic differences in unmet need for vision care among children with special health care needs.

Do specialist self-referral insurance policies improve access to HIV-experienced physicians as a regular source of care?

Health insurance policies that require prior authorization for specialty care may be detrimental to persons with HIV, according to evidence that having a regular physician with HIV expertise leads to improved patient outcomes. The objective of this study is to determine whether HIV patients who can self-refer to specialists are more likely to have physicians who mainly treat HIV. The authors analyze cross-sectional survey data from the HIV Costs and Services Utilization Study. At baseline, 67 percent of patients had insurance that permitted self-referral. In multivariate analyses, being able to self-refer was associated with an 8-12 percent increased likelihood of having a physician at a regular source of care that mainly treats patients with HIV. Patients who can self-refer are more likely to have HIV-experienced physicians than are patients who need prior authorization. Insurance policies allowing self-referral to specialists may result in HIV patients seeing physicians with clinical expertise relevant to HIV care.