Racial and ethnic disparities in inferior vena cava filter placement for deep vein thrombosis in the United States.

OBJECTIVE: We sought to determine whether racial and ethnic disparities existed in inferior vena cava (IVC) filter (IVCF) placement rates among Black and Latino patients for the treatment of acute proximal lower extremity (LE) deep vein thrombosis (DVT) in the United States from 2016 to 2019. METHODS: We performed a retrospective review of National Inpatient Sample data to identify adult patients with a primary discharge diagnosis of acute proximal LE DVT from January 2016 to December 2019, including self-reported patient race and ethnicity. IVCF placement rates were identified using International Classification of Diseases, 10th revision, codes. Weighted multivariable logistic regression was used to compare IVCF use by race and ethnicity. The regression model was adjusted for patient demographics (ie, sex, primary payer, quartile classification of household income), hospital information (ie, region, location, teaching status, bed size), weekend admission, and clinical characteristics (ie, modified Charlson comorbidity index, hypertension, atrial fibrillation, diabetes mellitus type 2, congestive heart failure, dyslipidemia, coronary artery disease, smoking, obesity, alcohol abuse, chronic kidney disease, pulmonary embolism, malignancy, contraindications to anticoagulation, including other major bleeding). RESULTS: Of 134,499 acute proximal LE DVT patients, 18,909 (14.1%) received an IVCF. Of the patients who received an IVCF, 12,733 were White (67.3%), 3563 were Black (18.8%), and 1679 were Latino (8.9%). IVCF placement decreased for all patient groups between 2016 and 2019. After adjusting for the U.S. population distribution, the IVCF placement rates were 11 to 12/100,000 persons for Black patients, 7 to 8/100,000 persons for White patients, and 4 to 5/100,000 persons for Latino patients. The difference in IVCF placement rates was statistically significant between patient groups (Black patients vs White patients, P < .05; Black patients vs Latino patients, P < .05; Latino patients vs White patients, P < .05). CONCLUSIONS: This nationwide study showed that Black patients have higher IVCF placement rates compared with White and Latino patients. Given the known long-term complications and uncertain benefits of IVCFs, coupled with the 2010 U.S. Food and Drug Administration safety warning regarding adverse patient events for these devices, proactive measures should be taken to address this disparity among the Black patient population to promote health equity. Future work should assess whether clinician bias might be perpetuating this disparity.

Contemporary nationwide trends and in-hospital outcomes of adjunctive stenting in patients undergoing catheter-directed thrombolysis for proximal deep venous thrombosis.

OBJECTIVE: Outflow venous stenting as an adjunct to catheter-directed thrombolysis (CDT) is performed to prevent recurrent thrombosis and to reduce the risk of post-thrombotic syndrome. Historical data show that stenting improves outcomes of surgical thrombectomy in patients with iliofemoral deep venous thrombosis (DVT), and recent observational data suggest that stenting improves long-term outcomes of CDT. However, the impact of stenting during CDT on acute safety outcomes is unknown. We sought to investigate the contemporary trends, safety outcomes, and resource utilization of adjunctive stent placement in patients undergoing CDT. METHODS: Patients with proximal lower extremity and caval DVT were identified within the National Inpatient Sample from January 2005 to December 2013. From this data set, we stratified our patients into three groups: patients who received CDT alone, patients who received CDT plus angioplasty, and patients who received CDT plus angioplasty with stenting. We used an inverse probability treatment weighting algorithm to create three weighted cohorts. Cochran-Armitage test was used to evaluate the trends of stent placement among patients treated with CDT. The primary outcome was a composite end point of all-cause mortality, gastrointestinal bleed, or intracranial hemorrhage. RESULTS: A total of 138,049 patients were discharged with a principal diagnosis of proximal and caval DVT; 7097 of these patients received CDT (5.1%). From this group, 2854 (40.2%) were treated with CDT alone, 2311 (32.6%) received adjunctive angioplasty alone, and 1932 (27.2%) received adjunctive angioplasty and stent. Adjunctive stenting had a significantly lower rate of primary composite outcome compared with CDT alone (2.7% vs 3.8%; P = .04). Stent placement was associated with a similar length of stay compared with angioplasty and CDT alone groups (6.8 vs 6.9 vs 7.1 days, respectively; P = .94) and higher in-hospital charges ($115,164.01 ± $76,985.31 vs $98,089.82 ± $72,921.94 vs $80,441.63 ± $74,024.98; P < .001). CONCLUSIONS: This nationwide study suggests that one in four patients undergoing CDT is treated with adjunctive stent placement in the United States. This observational study showed that adjunctive stenting does not adversely affect the acute safety outcomes of CDT; however, it was associated with increased hospital charges.

In-hospital outcomes of catheter-directed thrombolysis versus anticoagulation in cancer patients with proximal deep venous thrombosis.

OBJECTIVE: The objective of this study was to determine the rate of complications of catheter-directed thrombolysis (CDT) in cancer patients with deep venous thrombosis (DVT) compared with anticoagulation therapy alone. METHODS: This observational study used the National Inpatient Sample database to screen for any cancer patients who were admitted with a principal discharge diagnosis of proximal lower extremity or caval DVT between January 2005 and December 2013. Patients treated with CDT plus anticoagulation were compared with those treated with anticoagulation alone using propensity score matching for comorbidities and demographic characteristics. The primary end point was in-hospital mortality. Secondary end points were acute intracranial hemorrhage, inferior vena cava filter placement, acute renal failure, blood transfusion rates, length of stay, and hospital charges. RESULTS: We identified 31,124 cancer patients with lower extremity proximal or caval DVT, and 1290 (4%) patients were treated with CDT. Comparative outcomes as assessed in the two matched groups of 1297 patients showed that there was no significant difference in in-hospital mortality of patients undergoing CDT plus anticoagulation compared with those treated with anticoagulation alone (2.6% vs 1.9%; P = .23). However, CDT was associated with increased risk of intracranial hemorrhage (1.3% vs 0.4%; P = .017), greater blood transfusion rates (18.6% vs 13.1 %; P < .001), and higher rates of procedure-related hematoma (2.4% vs 0.4%; P < .001). The length of stay (6.0 [4.0-10.0] days vs 4.0 [2.0-7.0] days; P < .001) and hospital charges ($81,535 [$50,968-$127,045] vs $22,320 [$11,482-$41,005]; P < .001) were also higher in the CDT group compared with the control group. CONCLUSIONS: There was no significant difference in in-hospital mortality of cancer patients who underwent CDT plus anticoagulation compared with anticoagulation alone. CDT was associated with increased in-hospital morbidity and resource utilization compared with anticoagulation alone. Further studies are needed to examine the effect of CDT on the development of PTS in this population.

Prophylactic Inferior Vena Cava Filters Prior to Bariatric Surgery: Insights From the National Inpatient Sample.

OBJECTIVES: The aim of this study was to determine in-hospital mortality, post-surgical thromboembolic events, and health care costs associated with the placement of prophylactic inferior vena cava filters (IVCFs) prior to bariatric surgery. BACKGROUND: The role of prophylactic IVCFs prior to bariatric surgery is controversial, and the nationwide clinical outcomes associated with this practice are unknown. METHODS: This observational study used the National Inpatient Sample database to identify obese patients who underwent bariatric surgery from January 2005 to September 2015. Using propensity score matching, outcomes associated with patients receiving prophylactic IVCFs prior to their bariatric surgery were compared with those among patients who did not receive IVCFs. RESULTS: A total of 258,480 patients underwent bariatric surgery, of whom 1,047 (0.41%) had prophylactic IVCFs implanted. Patients with prophylactic IVCFs compared with those without IVCFs had a significantly higher rate of the combined endpoint of in-hospital mortality or pulmonary embolism (1.4% vs. 0.4%; odds ratio: 3.75; 95% confidence interval [CI]: 1.25 to 11.30; p = 0.019). Additionally, prophylactic IVCFs were associated with higher rates of lower extremity or caval deep vein thrombosis (1.8% vs. 0.3%; odds ratio: 6.33; 95% CI: 1.87 to 21.4; p < 0.01), length of stay (median 3 days vs. 2 days; p < 0.01), and hospital charges (median $63,000 vs. $37,000; p < 0.01). CONCLUSIONS: In this nationwide observational study, prophylactic IVCF implantation prior to bariatric surgery was associated with worse clinical outcomes and increased health care resource utilization.

Disparity in the use of adjuvant radioactive iodine ablation among high-risk papillary thyroid cancer patients.

BACKGROUND: We sought to identify treatment disparities existing prior to publication of the 2015 American Thyroid Association Management Guidelines in order to identify patients with papillary thyroid cancer (PTC) at risk for receiving inadequate treatment. METHODS: Patients diagnosed with PTC from 2011 to 2013 were identified using Surveillance, Epidemiology and End Results database. High-risk disease was defined as T4, N1, or M1. Chi-square tests compared characteristics of patients with and without high-risk disease and characteristics of high-risk patients who did and did not receive radioactive iodine ablation (RAI). Likelihoods of having high-risk disease, of receiving RAI, and of cause-specific death were calculated using regression analyses. RESULTS: Sample included 32,229 individuals; 7894 (24.5%) had high-risk disease. Mean age was 50.0 years, 24,815 (77.0%) were female, and 21,318 (66.2%) were white. Odds of high-risk disease were greater among males (OR:2.04; 95% CI:1.92-2.16), Hispanics (OR:1.67; 95% CI:1.56-1.79) and Asians (OR:1.49; 95% CI:1.37-1.62), and uninsured (OR:1.24; 95% CI:1.07-1.43), and lower among patients ages 45-64 (OR:0.57; 95% CI:0.53-0.60), and ≥65 years (OR:0.54; 95% CI:0.50-0.59), and Blacks (OR:0.46; 95% CI:0.40-0.53). Most (69.3%) high-risk patients received RAI. Odds of receiving RAI were lower among patients age ≥65 years (OR:0.67; 95% CI:0.58-0.77), uninsured (OR:0.52; 95% CI:0.41-0.67), or with Medicaid (OR:0.58; 95% CI:0.50-0.69). RAI use reduced the risk of cause-specific mortality (HR:0.29; 95% CI:0.18-0.47). CONCLUSION: Knowledge of these treatment disparities will allow recognition of groups at risk for high-risk disease and receiving inadequate treatment.

Contemporary Trends and Comparative Outcomes With Adjunctive Inferior Vena Cava Filter Placement in Patients Undergoing Catheter-Directed Thrombolysis for Deep Vein Thrombosis in the United States: Insights From the National Inpatient Sample.

OBJECTIVES: The aim of this study was to investigate the contemporary trends and comparative effectiveness of adjunctive inferior vena cava filter (IVCF) placement in patients undergoing catheter-directed thrombolysis (CDT) for treatment of proximal lower extremity or caval deep vein thrombosis. BACKGROUND: CDT is being increasingly used in the management of proximal deep vein thrombosis. Although a significant number of patients treated with CDT undergo adjunctive IVCF placement, the benefit of this practice remains unknown. METHODS: The National Inpatient Sample database was used to identify all patients with proximal or caval deep vein thrombosis who underwent CDT (with and without adjunctive IVCF placement) in the United States between January 2005 and December 2013. A propensity score-matching algorithm was then used to derive 2 matched groups of patients (IVCF and no IVCF) for comparative outcomes (mortality and major and minor bleeding) and resource use analysis. RESULTS: Of the 7,119 patients treated with CDT, 2,421 (34%) received IVCFs. There was no significant difference in in-hospital mortality (0.7% vs 1.0%; p = 0.20), procedure-related hemorrhage (1.4% vs. 1.0%; p = 0.23), or intracranial hemorrhage (0.7% vs. 0.6%; p = 0.70) between the IVCF (n = 2,259) and no-IVCF (n = 2,259) groups, respectively. Patients undergoing IVCF placement had higher rates of hematoma (3.4% vs 2.1%; p = 0.009), higher in-hospital charges ($104,049 ± 75,572 vs. $92,881 ± 80,194; p < 0.001) and increased length of stay (7.3 ± 5.6 days vs. 6.9 ± 6.9 days; p = 0.046) compared with the no-IVCF group. CONCLUSIONS: This nationwide observational study suggests that one-third of all patients undergoing CDT receive IVCFs. IVCF use was not associated with a decrease in in-hospital mortality but was associated with higher inpatient charges and longer length of stay.

A retrospective analysis of care in patients with dementia hospitalized at a tertiary medical center.

BACKGROUND: Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized. DESIGN: One hundred and thirty-one charts of patients with dementia admitted to a single university-based hospital were retrospectively reviewed. Data were collected and analyzed for age, gender, the severity of dementia, co-morbidities, co-existing vascular dementia, reversible causes of dementia, mental status scores, medications, consultations, procedures, complications, availability of advance directives, decision-maker, code status, and goals of care discussion. RESULTS: In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge. CONCLUSION: Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.

Sex differences in utilization and outcomes of catheter-directed thrombolysis in patients with proximal lower extremity deep venous thrombosis - Insights from the Nationwide Inpatient Sample.

Catheter-directed thrombolysis (CDT) is being increasingly used for the treatment of proximal lower extremity (LE) deep venous thrombosis (DVT). However, sex differences in utilization and safety outcomes of CDT in these patients are unknown. The Nationwide Inpatient Sample (NIS) database was used to identify all patients with a principal discharge diagnosis of proximal LE or caval DVT who underwent CDT between January 2005 and December 2011 in the United States. We evaluated the comparative safety outcomes of CDT among a propensity-matched group of 1731 men versus 1731 women. Among 108,243 patients with proximal LE or caval DVT, 4826 patients (4.5%) underwent CDT. Overall, women underwent CDT less often compared to men (4.1% vs 4.9%, p<0.01, respectively). The rates of CDT increased between 2005 and 2011 for both women (2.1% to 5.9%, p<0.01) and men (2.5% to 7.5%, p<0.01). There was no significant difference in in-hospital mortality (1.2% vs 1.3%, p=0.76). Women were noted to have higher rates of blood transfusions (11.7% vs 8.8%, p<0.01), but lower rates of intracranial hemorrhage (0.5% vs 1.2%, p=0.03) and gastrointestinal bleeding (0.9% vs 2.2%, p<0.01) compared with men. Women were more likely to undergo inferior vena cava filter placement (37.0% vs 32.1%, p<0.01). In this large nationwide cohort, women with proximal DVT were less likely to receive CDT compared to men. Although mortality rates were similar, women were noted to have higher blood transfusion rates while men had more episodes of intracranial and gastrointestinal bleeding.

Comparative outcomes of catheter-directed thrombolysis plus anticoagulation vs anticoagulation alone to treat lower-extremity proximal deep vein thrombosis.

IMPORTANCE: The role of catheter-directed thrombolysis (CDT) in the treatment of acute proximal deep vein thrombosis (DVT) is controversial, and the nationwide safety outcomes are unknown. OBJECTIVES: The primary objective was to compare in-hospital outcomes of CDT plus anticoagulation with those of anticoagulation alone. The secondary objective was to evaluate the temporal trends in the utilization and outcomes of CDT in the treatment of proximal DVT. DESIGN, SETTING, AND PARTICIPANTS: Observational study of patients with a principal discharge diagnosis of proximal or caval DVT from 2005 to 2010 in the Nationwide Inpatient Sample (NIS) database. We compared patients treated with CDT plus anticoagulation with the patients treated with anticoagulation alone. We used propensity scores to construct 2 matched groups of 3594 patients in each group for comparative outcomes analysis. MAIN OUTCOMES AND MEASURES: The primary study outcome was in-hospital mortality. The secondary outcomes included bleeding complications, length of stay, and hospital charges. RESULTS: Among a total of 90,618 patients hospitalized for DVT (national estimate of 449,200 hospitalizations), 3649 (4.1%) underwent CDT. The CDT utilization rates increased from 2.3% in 2005 to 5.9% in 2010. Based on the propensity-matched comparison, the in-hospital mortality was not significantly different between the CDT and the anticoagulation groups (1.2% vs 0.9%) (OR, 1.40 [95% CI, 0.88-2.25]) (P = .15). The rates of blood transfusion (11.1% vs 6.5%) (OR, 1.85 [95% CI, 1.57-2.20]) (P < .001), pulmonary embolism (17.9% vs 11.4%) (OR, 1.69 [95% CI, 1.49-1.94]) (P < .001), intracranial hemorrhage (0.9% vs 0.3%) (OR, 2.72 [95% CI, 1.40-5.30]) (P = .03), and vena cava filter placement (34.8% vs 15.6%) (OR, 2.89 [95% CI, 2.58-3.23]) (P < .001) were significantly higher in the CDT group. The CDT group had longer mean (SD) length of stay (7.2 [5.8] vs 5.0 [4.7] days) (OR, 2.27 [95% CI, 1.49-1.94]) (P < .001) and higher hospital charges ($85,094 [$69,121] vs $28,164 [$42,067]) (P < .001) compared with the anticoagulation group. CONCLUSIONS AND RELEVANCE: In this study, we did not find any difference in the mortality between the CDT and the anticoagulation groups, but evidence of higher adverse events was noted in the CDT group. In the context of this observational data and continued improvements in technology, a randomized trial with outcomes such as mortality and postthrombotic syndrome is needed to definitively address this comparative effectiveness.

Assessment of technique during pediatric direct laryngoscopy and tracheal intubation: a simulation-based study.

OBJECTIVES: This study aimed to assess the feasibility of characterizing direct laryngoscopy (DL) and tracheal intubation (TI) technique based on videographic review and to determine the association between technical aspects of DL and TI with successful completion of intubation. METHODS: Physicians in pediatrics, emergency medicine, pediatric emergency, pediatric critical care, and neonatology performed TI on simulators (newborn, infant, and adult). A video laryngoscope was used without a display (ie, as a direct laryngoscope), and video recordings were reviewed. A scoring instrument characterized technical aspects of DL and TI; outcomes related to procedural performance were recorded. Interrater reliability of the instrument was assessed by weighted κ; collinearity was assessed by a correlation matrix. Univariate analysis determined technical aspects of DL and TI associated with outcomes. RESULTS: Seventy-three subjects performed 206 intubations. Significant differences existed between simulators with respect to the first-attempt success (newborn, 63%; infant, 80%; adult, 42%; P < 0.001), laryngoscopy time (27 seconds vs 31 seconds vs 42 seconds, P < 0.001), and percentage of glottic opening score (68% vs 65% vs 35%, P < 0.001). Interrater reliability for the instrument was good (κ = 0.68); no significant collinearity existed between data points. Position of the tip of the laryngoscope blade in the vallecula and under the proximal epiglottis was associated with improved first-attempt success. CONCLUSIONS: Pediatric intubation technique can be reliably assessed using videography and video laryngoscopy. Future studies should examine video-based characterization of DL and TI technique in real patients outside the operating room, as well as whether technical aspects of intubation are associated with improved outcomes.

Voices of Asian American youth: important characteristics of clinicians and clinical sites.

OBJECTIVE: The purpose of this work was to explore clinician and site characteristics that are important to Chinese and Vietnamese immigrant and first-generation youth. METHODS: A 3-stage mixed qualitative-quantitative design consisting of exploratory focus groups, a survey, and explanatory focus groups was used to ensure that all of the ideas were generated, prioritized, and explained by youth. Adolescents of Chinese and/or Vietnamese descent and aged 13 to 18 years were recruited in community centers and schools. In stage 1, 55 adolescents in 8 focus groups shared their views on factors that attract or deter them from seeking care. In stage 2, youth responded to a survey including 27 teen-generated items regarding clinicians and sites. In stage 3, 87 teens in 11 groups explained the top-rated items and offered suggestions on how to meet their needs. All of the stages were conducted in English, Mandarin Chinese, and Vietnamese. RESULTS: Most of the 245 survey respondents (77%) were born in Asia, and 70% had lived in the United States for <3 years. The 27 items were divided into 6 priority ranks by the marginal homogeneity test. Clinician cleanliness and experience shared first rank. Second rank was shared by Asian teens being treated like other teens, site cleanliness, clinician honesty, and clinician friendliness and attitude. The third rank was shared by respect, privacy, completeness, clinicians explaining their actions, and lower health care costs. Interspersed among ranks 5 and 6 were items specific to the needs of Asian youth: the clinician would offer more explanation because Asian families might not ask questions; the clinician would not assume that Asian teens are drug and sex free; the clinician would understand that Asian families may use traditional healing; the clinician would not assume that Asians do not know English; adolescents would not translate for parents; and the teen would be able to choose an Asian clinician. There was little variation in ratings by age, gender, ethnicity, or socioeconomic status. However, 11 of 27 items differed by acculturation. Examples include the greater importance ascribed by more acculturated youth to not being judged, to not having to translate, and to the clinician addressing behavioral issues. Acculturation also affected the youths' views regarding confidentiality and translation. CONCLUSIONS: Asian American adolescents value the same concerns as all adolescents: respect, honesty, competency, cleanliness, privacy, and nonjudgmental service. However, they also have unique perspectives, and youth at varying levels of acculturation differ in some of their views.

Disparities in the reporting and treatment of health conditions in children: an analysis of the Medical Expenditure Panel Survey.

OBJECTIVES: To determine whether racial and ethnic disparities in health care use differ for physical and behavioral health conditions. DATA SOURCES: Secondary analysis of the 1996-1997 Medical Expenditure Panel Survey. STUDY DESIGN: Retrospective cohort study of children aged 2-18 years old who were members of participating households. Children were categorized as Hispanic, black, or white. Differences in caregiver-reported behavioral and physical health conditions and services use were compared, and estimates were weighted to reflect the complex sampling scheme. PRINCIPAL FINDINGS: Of eligible children weighted to represent over 44 million in each year, 13-15 percent were Hispanic, 14 percent black, and 68-70 percent white. After adjusting for potential confounding, Hispanic and black children were less likely to report externalizing behavioral conditions than white children. Black but not Hispanic children were more likely than white children to report asthma. In addition, Hispanic and black children were less likely to report ambulatory visits, and black children were less likely to report receiving a prescription medication than white children. There were no differences in reported emergency room visits or hospitalizations. Interactions between race and various health conditions, health status, insurance, and income were not significant. CONCLUSIONS: In this nationally representative sample, we identified racial and ethnic disparities in the reporting of health conditions and the use of discretionary health services. Disparities differed between those with behavioral conditions and those with physical conditions. These disparities were not explained by traditional measures including the presence of health conditions, health status, insurance, and family income, and suggest that national surveys such as Medical Expenditure Panel Survey may benefit from the inclusion of additional explanatory measures.

National estimates of health services expenditures for children with behavioral disorders: an analysis of the medical expenditure panel survey.

BACKGROUND: Children with attention-deficit/hyperactivity disorder and asthma incur similar health care costs that are greater than those of most children without these conditions. Preliminary findings suggest that children with emotional behavioral disorders, anxiety and depression, incur even greater costs. OBJECTIVE: To determine if children with behavioral disorders have similar health services expenditures as children with physical conditions and to assess whether children with emotional behavioral disorders incur greater expenditures than children with disruptive behavioral disorders. METHODS: Children 2 to 18 years old who were members of households participating in the 1996 Medical Expenditure Panel Survey were eligible for this retrospective cohort study. Children with common behavioral disorders selected a priori were identified by using truncated International Classification of Diseases (Ninth Revision) codes obtained from household interviews. Children with common physical conditions (asthma, epilepsy, and diabetes) and children without these conditions served as controls. Estimates were weighted to reflect the complex sampling scheme. Expenditures for health services were compared. RESULTS: Of 3955 eligible children weighted to represent >44 million, 7.1% were identified with a behavioral disorder: 4.5% with disruptive disorders; 2.1% with emotional disorders; and 0.5% with miscellaneous disorders. Children with behavioral disorders incurred overall expenditures similar to children with physical conditions (adjusted 1492 dollars vs 1245 dollars; P =.18) but greater than children without these conditions (adjusted 1492 dollars vs 834 dollars; P =.001). Children with behavioral disorders had greater expenditures for office-based visits (adjusted 410 dollars; 95% confidence interval: 146-672 dollars) and prescription medications (adjusted 361 dollars; 95% confidence interval: 72-648 dollars) than those of children in either control group. Among children with behavioral disorders, children with emotional disorders incurred substantially greater overall expenditures (adjusted 2152 dollars vs 1026 dollars; P =.003) than children with disruptive disorders. Children with emotional disorders incurred greater hospitalization expenditures (664 dollars vs 43 dollars; P =.01) but lower pharmacy expenditures (154 dollars vs 307 dollars; P =.001) than children with disruptive disorders. CONCLUSIONS: In this nationally representative sample, children with behavioral disorders incurred overall health care costs similar to children with physical conditions but greater than children without any of these conditions because of increased costs for office-based visits and prescription medications. However, costs were not uniform among children with behavioral disorders. Children with emotional disorders incurred twofold higher costs than children with disruptive disorders. Greater recognition of children with emotional disorders and efforts to address the high rate of hospitalizations in this population are warranted.

How to reach sexual minority youth in the health care setting: the teens offer guidance.

PURPOSE: To explore factors sexual minority youth believe make them feel safe in a health care setting. METHODS: Participants in three urban programs serving lesbian/gay/bisexual/transgendered and questioning (LGBTQ) youth engaged in a four-stage process to generate, prioritize, and explain their own ideas. In Stage III, 94 youth, aged 14 to 23 years, completed a survey comprised of the 34 highest rated items generated in earlier stages. Using a Likert scale, they answered, "How important are each of the following ideas in making you feel safe as an LGBTQ youth when you go for health care?" In Stage IV, youth discussed the results in focus groups. The Marginal Homogeneity Test divided the items into priority ranks and the Kruskal-Wallis test explored subgroup differences in item ratings. RESULTS: The 34 items were divided into six ranks. Five items shared the top rank: the clinician maintaining privacy, demonstrating cleanliness, offering respect, being well-educated, and being honest. The second rank was shared by the following: the clinician not talking down to patients, being a good listener, not downplaying patients' fears, being professional, holding a nonjudgmental stance of the LGBTQ lifestyle, and not assuming every LGBTQ youth has HIV. Interspersed among other ranks were items specific to the needs of sexual minority youth: the clinician not assuming LGBTQ sexual behavior was painful or dangerous; the clinician being educated about the gay lifestyle; clinician sensitivity to the needs of same-sex partners; staff sensitivity to the needs of closeted youth; having a choice of an LGBTQ provider; and the clinician not assuming heterosexuality. Youth who had not publicly disclosed their sexuality rated health information being offered in a private place higher (p =.01). CONCLUSIONS: LGBTQ youth value the same clinician characteristics desired by all adolescents: privacy, cleanliness, honesty, respect, competency, and a nonjudgmental stance. They clearly describe what attracts them (e.g., clinicians educated about their lifestyle) and what offends them (e.g., equating their sexuality with HIV). Clinicians need to achieve and convey a higher comfort level in addressing the special needs of sexual minority youth.