Use of videotaping to evaluate pediatric resident performance of health supervision examinations of infants.

STUDY OBJECTIVES: To demonstrate reliability of a method for evaluating pediatric resident performance of health supervision examinations of infants using real patients and to evaluate pediatric resident performance of health supervision examinations of infants before and after an educational intervention consisting of a 6-month ambulatory rotation combined with video-assisted review of resident performance of the examination. DESIGN: Longitudinal cohort study in which all second-year residents were enrolled. Residents' preintervention (baseline) videotapes were compared with postintervention videotapes. Each resident served as his or her own control. SETTING: University hospital pediatric resident continuity clinic. SUBJECTS: Sixteen second-year pediatric residents who were participating in a required 6-month ambulatory rotation. METHOD AND MAIN RESULTS: Reliability study: Using a 51-item instrument derived from the American Academy of Pediatrics Guidelines for Health Supervision, trained raters blind to the sequence and dates of the videotaped health supervision examinations independently rated 44 resident encounters (a minimum of two raters per tape) and achieved good interrater reliability (kappa = 0.80). Intervention study: After a 6-month ambulatory rotation which included resident-faculty reviews of preintervention videotapes, residents showed a 14% mean improvement in performance scores for the examination (P < .05). CONCLUSIONS: The results indicate that videotaped health supervision examinations using real patients can be reliably evaluated by observational techniques in a continuity practice. A 6-month ambulatory block rotation coupled with video-assisted interactive review of examinations is associated with measurable improvement in resident performance on the postintervention test.

The effect of medical conditions on the functional limitations of Mexican-American elderly.

We examined the relationship of self-reported functional status to common medical conditions using a probability sample of 3050 noninstitutionalized Mexican-American men and women aged 65 or older and residing in the Southwestern United States (Arizona, California, Colorado, New Mexico, and Texas). All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. The questionnaire obtained information on self-reported functional status and prevalence of arthritis, cancer, diabetes, stroke, heart attack, and hip fracture. The prevalence of medical conditions ranged from 4.1% for hip fracture to 40.8% for arthritis. Prevalence of impairments in seven activities of daily living ranged from 5.4% for eating to 11.7% for bathing, while 25.1% could not walk up and down stairs, and 28.9% could not walk a half mile without help. In multiple logistic regression analyses, previous diagnoses of stroke and hip fracture were most predictive of functional limitations, though all conditions examined (arthritis, cancer, diabetes, stroke, heart attack, and hip fracture) were independently associated with increased odds of impairment in some activities of daily living. In general, the odds for functional impairment associated with specific medical conditions were higher than those previously published for non-Hispanic white populations. The fact that Mexican-American elderly who live in the community and who have medical conditions, especially stroke and hip fracture, are at high risk for functional impairment probably reflects the low rate of institutionalization in this population and has implications for the provision of community-based long-term care services for Mexican-American elderly.

Relationship between low blood pressure and depressive symptomatology in older people.

OBJECTIVES: To determine if low blood pressure is associated with a definable constellation of somatic and psychological symptoms in older persons. DESIGN: A population-based study. SETTING: In-home interviews in five southwestern states. PARTICIPANTS: A total of 2723 Mexican Americans aged 65 or older not living in institutions. MEASURES: Blood pressure, Center for Epidemiologic Studies Depression Scale (CES-D), global self-rating of health, and self-esteem. RESULTS: Bivariate analyses indicate a significant relationship between low blood pressure and increased depressive symptomatology; for example, systolic hypotensive subjects scored a CES-D mean of 12.07 +/- .67 compared to 8.99 +/- .95 for normotensives (P < .01). Regression analyses supported these findings when controlling for confounders such as gender, age, and use of antihypertensive medications. Subjects with low blood pressure also scored lower on self-esteem and global self-reported health and reported more days waking up feeling tired. CONCLUSIONS: These data support the existence of a relationship between low blood pressure and higher levels of depressive symptomatology as well as a constellation of somatic and psychosocial symptoms.

Undertreatment of hypertension in older Mexican Americans.

OBJECTIVE: To identify the prevalence of hypertension and factors associated with nontreatment and poor control of hypertension in Mexican Americans aged 65 years and older. DESIGN: A population-based survey of older Mexican Americans conducted in 1993-1994. SETTING: Subjects residing in five Southwestern states: Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: An area probability sample of 3050 noninstitutionalized Mexican American men and women aged 65 and older took part in a 90-minute in-home interview, which included review of all medications taken and two sitting blood pressure measurements. OUTCOME MEASURES: Measured were previous diagnoses of hypertension, current medication for hypertension, and current blood pressure RESULTS: Sixty-one percent of older Mexican-Americans were hypertensive, and 51% of those with hypertension were taking antihypertensive medications. Only 25% of hypertensive subjects (18% of males and 30% of females) were in good blood pressure control (i.e., systolic blood pressure < 140 mm Hg and diastolic blood pressure < 90 mm Hg). In multivariate analyses, factors associated with increased likelihood of treatment included female gender (OR = 1.9), history of heart disease (OR = 2.4), possessing a regular source of health care (OR = 2.7), and having seen a physician two or more times in the previous year (OR = 3.8). These were also independent predictors of good blood pressure control. CONCLUSION: Nontreatment of hypertension is still a major public health concern in older Mexican Americans. We estimate that adequate blood pressure control in this population would prevent approximately 30,000 adverse cardiovascular events over 10 years, affecting approximately 6% of the entire Mexican American older population.

Changes in blood pressure and risk factors for cardiovascular disease among older Mexican-Americans from 1982-1984 to 1993-1994.

OBJECTIVE: To determine the 10-year changes in blood pressure and cardiovascular risk factors among older Mexican-Americans. DESIGN: Comparative analyses of the Hispanic Health and Nutrition Examination Survey (HHANES) and the Hispanic EPESE (Established Populations for Epidemiologic Studies of the Elderly). Both of these were population-based studies using a multistage stratified probability sampling design of noninstitutionalized persons. SETTING: Five US states in the southwest: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 216 Mexican-Americans aged 65 to 74 from the 1982-1984 HHANES and 3050 Mexican-Americans aged 65+ from the 1993-1994 Hispanic EPESE. MEASUREMENTS: Mean systolic and diastolic blood pressure; cigarette smoking; high levels of alcohol use; body mass index and obesity; self-reported heart attack, stroke, and diabetes; hypertension. RESULTS: Among 65- to 74-year-old Mexican-Americans, there was a decrease over time in the percent of those who smoked cigarettes from 27.60% to 13.96% and a decrease in mean systolic blood pressure level. The percent of subjects categorized as obese or severely obese increased significantly, as did the prevalence of diagnosed diabetes, increasing from 20.06% in 1982-1984 to 29.82% in 1993-1994. Mean diastolic blood pressure increased from 77.15 mm Hg in 1982-1984 to 81.21 mm Hg in 1993-1994. CONCLUSIONS: Our findings suggest major changes in cardiovascular risk factors between 1982-1984 and 1993-1994 among older Mexican-Americans.

Correlates of prescription and over-the-counter medication usage among older Mexican Americans: the Hispanic EPESE study. Established Population for the Epidemiologic Study of the Elderly.

OBJECTIVES: To determine the prevalence rates of prescription and over-the-counter (OTC) medication usage among community-dwelling older Mexican Americans. DESIGN: Cross-sectional survey of a regional probability sample of older Mexican Americans. SETTING: The 1992-1997 Hispanic Established Population for the Epidemiologic Study of the Elderly (H-EPESE), a probability sample of noninstitutionalized Mexican Americans, age 65 and over, living in the five Southwestern states of Texas, New Mexico, Colorado, Arizona, and California. PARTICIPANTS: 2899 persons, age 65 and over, considered Mexican American, using appropriate weighting procedures to produce regional estimates. OUTCOME MEASURES: Use of prescription and OTC medication within the last 2 weeks before the survey confirmed by in-home review of medication containers. RESULTS: Medication users consumed a mean of 2.9 prescription and 1.3 OTC medications. Over half (58.9%, n = 1,798) of the participants used at least one prescribed medication, and 31.3% (n = 847) used at least one OTC medication within the 2 weeks before their participation in the study. Factors associated with both prescription and OTC medication usage were self-perceived health and number of co-morbid conditions. Factors associated only with prescription medication usage included female gender, alcohol usage, ADL dependency, and presence of additional insurance. Structural assimilation was associated only with OTC medication usage. CONCLUSIONS: These data show lower prevalence rates of prescription medication usage among Mexican American older men and lower rates of OTC medication usage in older Mexican Americans of both genders than previously reported in other ethnic groups. This may reflect differences in time and geographic location of the Hispanic EPESE relative to other EPESE studies, ethnic differences in access to care as reflected by insurance in addition to Medicare, ethnic differences in survival, especially among males, or ethnic differences in medication preferences.

Lower-extremity functioning in older Mexican Americans and its association with medical problems.

OBJECTIVE: To describe lower-extremity functioning in community-dwelling older Mexican Americans and to examine its relationship with medical problems. DESIGN: Cross-sectional analyses of survey and performance-based data obtained in a population-based study employing area probability sampling. SETTING: Households within selected census tracts of five Southwestern states: Arizona, California, Colorado, New Mexico, and Texas. PARTICIPANTS: A total of 2873 Mexican Americans aged 65 years and older. MEASUREMENTS: A multidimensional questionnaire assessing demographic, sociocultural, and health variables. Standardized tests of lower-extremity physical functioning included measures of standing balance, repeated chair stands, walking, and an overall summary measure. RESULTS: Regression analyses revealed that being more than age 75 and female, having arthritis diabetes, visual impairments, or being obese or underweight were all significantly associated with performance on both individual and summary tests of lower-extremity functioning. In separate regression analyses, the total number of medical conditions was also associated with performance. CONCLUSIONS: The likelihood of predicting performance or inability to complete tests of lower-extremity functioning was greatest for those aged 80 and older, those with arthritis or diabetes, and those with three or more medical conditions. Because of the high prevalence of diabetes in Mexican Americans, documentation of the association of diabetes with performance-based tests of lower-extremity functioning may help guide early interventions targeted to prevent progression to more severe limitations or disability.

The measurement of health-related quality of life: major dimensions identified by factor analysis.

The measurement of quality of life is becoming more important in the evaluation of medical technologies and pharmaceuticals. Particularly when the several available therapies have similar effects on survival, quality of life measures may help decide which should be the therapy of choice. The Recovery Study utilized a multidisciplinary array of indicators of health-related quality of life and recovery. This paper reports factor analyses of 58 outcome measures on a study group of 469 persons who had undergone coronary artery bypass or cardiac valve surgery 6-months previously. The factor analyses revealed 5 orthogonal dimensions. We have named them: low morale, symptoms of illness, neuropsychological function, interpersonal relationships, and economic-employment. The data argue that health-related quality of life is a multidimensional construct, and that these dimensions can be measured quantitatively with relatively simple interview and questionnaire approaches. The next research step is to determine whether the five dimensions of post-operative quality of life have different pre-operative predictors, and whether intervention on these predictors can improve the recovery and rehabilitation process.

Impact of selected medical conditions on self-reported lower-extremity function in Mexican-American elderly.

OBJECTIVE: To examine the independent impact of common medical conditions on lower-extremity function in Mexican-American elderly. DESIGN: Cross-sectional study using a probability sample of non-institutionalized Mexican Americans aged 65 or older. SETTING: The five Southwestern states, Texas, New Mexico, Arizona, Colorado and California. PARTICIPANTS: All subjects were interviewed in person (n = 2,873) or by proxy (n = 177) in their homes during late 1993 and early 1994. MAIN OUTCOME MEASURES: Respondents were asked whether they could perform four activities related to lower-extremity function without help: walking across a small room, getting from a bed to a chair, walking up and down stairs, and walking half a mile. A summary measure of lower body disability created from these four items was regressed on seven common medical conditions plus five control variables using multiple logistic regression. RESULTS: Adjusted Odds Ratios (OR) suggested that impaired lower-extremity function was associated with previous diagnosis of hip fracture (OR = 4.28), stroke (OR = 3.47), lower extremity arthritis (OR = 2.60), heart attack (OR = 2.29), diabetes (OR = 2.03) and obesity (OR = 1.50). Impaired lower-extremity function was significantly associated with older age (75+ years old), gender (female) and marital status (unmarried). In addition, there was a linear increase in the risk of function loss by number of medical conditions. CONCLUSIONS: It appears that Mexican-American elderly diagnosed with medical conditions, especially stroke and hip fracture, have a high risk for lower-extremity dysfunction. These findings have implications for efforts to prevent or reduce lower-extremity dysfunction, as well as for the provision of community-based long-term care services for Mexican-American elderly.

Reproductive characteristics of Mexican-American, mainland Puerto Rican, and Cuban-American women Data from the Hispanic Health and Nutrition Examination Survey.

Data from the Hispanic Health and Nutrition Examination Survey were used to investigate reproductive characteristics of Hispanic females aged 15 to 45 years. Mexican-American and Puerto Rican women reported approximately 1.9 and 1.7 live births each, respectively, whereas Cuban-American women reported 1.1. Mexican-American women were more likely to be using oral contraceptives and were more likely to have had a hysterectomy or an oophorectomy than were Cubans and Puerto Ricans. The largest percentage of tubal ligations were found among Puerto Rican women. Mexican women who had been pregnant in the previous 12 months were more likely than their Puerto Rican and Cuban-American counterparts to be breastfeeding. Further research is needed to investigate the decision processes and/or cultural variations that may be responsible for these differences in reproductive traits across national origin groups.

Alcohol consumption patterns among Mexican American mothers and among children from single- and dual-headed households: findings from HHANES 1982-84.

Data from the southwestern United States sample of the Hispanic Health and Nutrition Examination Survey were employed to compare the patterns of alcohol use among Mexican American mothers and children in female-headed households with use patterns among mothers and children in couple-headed households. Single female heads of household drank more alcoholic beverages on more days than females from dual-headed households. As a whole, the children of single heads of household still living at home did not demonstrate significantly different drinking patterns from their dual-headed household counterparts. While male children of single-headed households drank more days and total drinks than their dual-headed household counterparts, female children of dual-headed households drank more days and total drinks than female children from single-headed households.

Acculturation and alcohol consumption in the Mexican American population of the southwestern United States: findings from HHANES 1982-84.

Data from the Southwestern sample of the Hispanic HANES are employed to evaluate the relationship of acculturation into the larger society with alcohol consumption. As in previous work, acculturation was not found to be related to alcohol consumption of Mexican American men, but was positively related to the consumption of younger Mexican American women. Among middle-aged women, acculturation was not important. However, we found evidence that middle-aged women might be turning to alcohol in response to marital disruption and poverty. In addition, middle-aged women who are not employed are less frequent drinkers but those who drink are heavier drinkers than employed women.

Health insurance coverage and utilization of health services by Mexican Americans, mainland Puerto Ricans, and Cuban Americans.

This investigation examines data on 13,000 Mexican Americans, Puerto Ricans, and Cuban Americans between 6 months and 74 years of age who were interviewed from 1982 through 1984 in the Hispanic Health and Nutrition Examination Survey. In addition, data from the 1989 Current Population Survey (N = 145,000) conducted by the US Bureau of the Census are presented for the white and black non-Hispanic populations as well as the three Hispanic national origin groups. The study revealed that over one third of the Mexican-American population, one fifth of the Puerto Rican population, and one fourth of the Cuban-American population is uninsured for medical expenditures compared with one fifth of the black, non-Hispanic population and one tenth of the white, non-Hispanic population. Furthermore, compared with Hispanics with private health insurance, uninsured Hispanics are less likely to have a regular source of health care, less likely to have visited a physician in the past year, less likely to have had a routine physical examination, and less likely to rate their health status as excellent or very good.