Pain in aging community-dwelling adults in the United States: non-Hispanic whites, non-Hispanic blacks, and Hispanics.

UNLABELLED: Racial and ethnic disparities in healthcare persist in the U.S. Although pain is one of the most prevalent and disabling symptoms of disease, only a few studies have assessed disparities in pain in large racially and ethnically diverse, middle- to late aged community samples, thus limiting the generalizability of study findings in broader populations. With data from the 2000 Health and Retirement Study, we assessed the prevalence and impact of pain in a community sample of aging (> or =51 years old) non-Hispanic whites (n = 11,021), non-Hispanic blacks (n = 1,804), and Hispanics (n = 952) in the U.S. Pain, pain severity, activity limitation as a result of pain, comorbid conditions, and sociodemographic variables were assessed. Results showed that pain prevalence was 28%, and 17% of the sample reported activity limitation as a result of pain. Non-Hispanic blacks (odds ratio [OR], 1.78; 99% confidence interval [CI], 1.33-2.37) and Hispanics (OR, 1.80; 99% CI, 1.26-2.56) had higher risk for severe pain compared with non-Hispanic whites. Analyses of respondents with pain (n = 3,811) showed that having chronic diseases (2 comorbid conditions, OR, 1.5; 99% CI, 1.09-2.17), psychological distress (OR, 1.99; 99% CI, 1.54-2.43), being a Medicaid recipient (OR, 1.63; 99% CI, 1.17-2.25), and lower educational level (OR, 1.45; 99% CI, 1.14-1.85) were significant predictors for severe pain and helped to explain racial/ethnic differences in pain severity. PERSPECTIVE: This study, which used a large racially and ethnically diverse community sample, provided empirical evidence that racial/ethnic difference in pain severity in aging community adults in the U.S. can be accounted for by differential vulnerability in terms of chronic disease, socioeconomic conditions, and access to care.

What predicts the quality of advanced cancer care in Latin America? A look at five countries: Argentina, Brazil, Cuba, Mexico, and Peru.

Cancer is now a leading cause of death among adults in most Latin American nations. Yet, until recently, there has been limited research on the quality of, and access to, advanced cancer care in developing regions such as Latin America. This landmark, cross-national study assessed the quality of advanced cancer care in five Latin American countries by surveying a convenience sample of 777 physicians and nurses, and identifying the most salient influences on their quality-of-care assessments based on multiple linear regression analyses. Strategies for disseminating this survey included mass mailings, distribution at professional meetings/conferences, collaboration with Latin American institutions, professional organizations, and the Pan American Health Organization, and online posting. Results indicate that the respondents' assessments of the quality of, access to, and affordability of advanced cancer care varied significantly across nations (P<0.001). The strongest predictor of providers' national-level assessments of the quality of care was their ratings of access to advanced cancer care (Beta=0.647). Other predictors included affordability of care, country (Cuba vs. the other four countries), income-gap quintile, and institutional availability of opioid analgesics. Low prioritization of palliative care in both health care policy formulation and provider education also predicted the quality-of-care ratings. Findings from this study suggest that providers from five different nations hold similar equitable notions of quality care that are dependent on the provision of accessible and affordable care. Measures of social equity, such as the income-gap quintile of nations, and measures of policy barriers, such as the scale developed in this study, should be replicated in future studies to enable policy makers to assess and improve advanced cancer care in their countries.

Mail versus internet surveys: determinants of method of response preferences among health professionals.

The authors evaluated determinants of response to Internet-based surveys in a sample (n = 5600) of Texas healthcare professionals. Participants were given the option of responding by mail or over the Web (response, 66%). Internet respondents were younger (p < .001), had worked fewer years in healthcare (p < .001), and were more likely to be male (p < .001) and to work in a hospital (p = .007). Missing questionnaire items were significantly higher among Web responders with regard to age, sex, race, body mass index, and smoking (p < .001). In the final multivariate logistic regression, only male gender (odds ratio [OR] = 2.09, 95% CI = 1.56-2.80) and younger age remained significantly associated with response over the Internet. Age quartile and responding electronically were inversely associated. Taken together with a priori knowledge of the demographic and professional profile of a study population, these findings can be useful in planning and implementation of surveys among healthcare workers.

Pain, depression, and fatigue in community-dwelling adults with and without a history of cancer.

The State of the Science Report by the National Cancer Institute on Symptom Management in Cancer identified gaps in understanding the epidemiology of pain, depression, and fatigue, and called for studies that will identify the extent of risk for these symptoms among those with cancer relative to other populations. Using year 2000 data from the Health and Retirement Study, a survey of a nationally representative sample of adults aged > or =50, we evaluated whether respondents with a history of cancer had excess risk for pain, depression, and fatigue compared to those without a history of cancer. We also compared clustering/co-occurrence of symptoms. Controlling for the confounding effects of comorbidities, sociodemographic, and access to care factors, respondents with a history of cancer had higher risk for fatigue (OR = 1.45; 95%CI = 1.29,1.63), depression (OR = 1.21; 95%CI = 1.06,1.37), and pain (OR = 1.15; 95%CI = 1.03,1.28). Symptom clusters were also more prevalent among those with a history of cancer (P < 0.001), with the pain-depression-fatigue cluster as most prevalent.

An urban community's preferences for hypothetical outcomes of analgesic pain treatment.

We assessed preferences of urban residents regarding hypothetical treatment outcomes related to analgesic use to determine how well subjects understood the severity of the outcomes, describe community preferences for these outcomes, and identify predictors of preferences. In a cross-sectional telephone survey, we obtained mean ratings for hypothetical outcomes that included two dimensions of clinical pain (pain severity and potential side effects): A=moderate pain, three side effects; B=mild pain, three side effects; C=moderate pain, one side effect. We focused on 111 respondents who rated Outcome A, moderate pain with three side effects, as the worst condition (the logical choice). Being Spanish speaking predicted preferences across treatment Outcomes A and B. Spanish-speaking subjects and those in fair to poor health tended to view all three outcomes more negatively than other respondents. Knowledge of public preferences can help clinicians better understand factors that influence treatment choices and may help them motivate their patients to adhere to analgesic regimens.

Access to health care in a rural area of the Philippines.

This study reports the results of a household survey requested by the mayor and community health officials in an under-served and understudied rural town in the Philippines. The study examines the extent and determinants of access to care. Results showed that 15% had a check-up in the previous year, despite 63% reporting a family history of chronic diseases. Multivariate regression analyses showed that having a usual source of care (P=.006) and education (P = .04) were predictors of having had a checkup the previous year. This study, which represents the first household survey assessing access to care in this rural Filipino population, provides empiric evidence supporting the need for health programs that will improve access to care and routine monitoring of chronic illness in this under-served, rural population.

Perceptions of analgesic use and side effects: what the public values in pain management.

In this population-based telephone survey, we evaluated the attitudes of 302 adults toward analgesic use and related side effects. Over half (68%) reported prior experience with 2 or more side effects. Vomiting (34%), confusion (32%), and nausea (17%) were ranked as the worst side effects. Exploratory cluster analysis grouped responses to 6 questions about willingness to use analgesics into two categories. Participants in Cluster I (n=106), "Conservatives," were less willing to take analgesics for pain as compared to those in Cluster II (n=153), "Liberals." Univariate analysis found Hispanics, women, those less affluent or educated, and those with prior side-effect experience were more likely to be Conservative. Experience with side effects (OR=1.3) and being female (OR=2.1) were the strongest predictors of conservative cluster membership. To achieve better pain outcomes, clinicians and patients must identify factors that contribute to conservative decision-making about analgesic use and side effect management.

Expanding the scope of health reform: application in the United States.

Since the demise of the Clinton national health plan in the early 1990s, a number of states in the US have continued to pursue health reform. The reforms reflect the on-going debate in the US and throughout the world over market-minimizing versus market-maximizing strategies to improve healthcare systems. This paper describes the limits of this debate and supports a broader view that focuses on how health policy can improve population health. Performance measures and indicators traditionally used to evaluate market minimizing/maximizing strategies for reforming healthcare are redefined for evaluating strategies to improve health. Differences in the two views are illustrated by describing state reforms in the US using the market-minimizing/maximizing framework and evaluating the reforms based on the health-related framework.

Factors associated with health-related quality of life among an older population in a largely rural western region.

CONTEXT: As elderly people become a larger proportion of the rural population, it is important to identify those at risk for poor health. Predictors of health-related quality of life can be useful in designing interventions. PURPOSE: One objective of the present study was to profile the health-related quality of life of community-dwelling, elderly people in a southwestern region of the United States. A related objective was to identify the principal factors associated with health-related quality of life, thereby identifying population subgroups in greatest need of health or social services. METHODS: A telephone survey of approximately 5,000 individuals 65 years and older collected data on need for assistance with activities of daily living, physical and mental health-related quality of life, and worry about health status measures. A modified version of the Behavioral Model was used to more clearly distinguish the different groups at risk for poor health. FINDINGS: Those groups of community-dwelling, elderly people in the poorest health were older than 75 years, had less than a high school education, were retired or unemployed, and had low household income. No differences were found by urban, rural, and frontier residence. CONCLUSIONS: To maintain the physical, social, and psychological health of older people residing in rural and urban areas, social services, medical care, and supportive services are needed, particularly among the most socially and economically disadvantaged.

Factors associated with hospital mortality in traumatic injuries: incentive for trauma care integration.

OBJECTIVES: The main aim of this study was to contrast the variation in mortality between trauma centres (TCs) and non-trauma hospitals (NTHs) in Texas, and among TCs by sociodemographic and economic factors of trauma cases. STUDY DESIGN: Difference in fatality due to trauma by hospital type was studied for all injured cases hospitalized over a 2-year period. METHODS: The outcome measure was mortality following an injury for cases that survived the impact and were treated in any hospital. Logistic regressions were employed to compare the risk factors associated with trauma fatalities between TCs and NTHs, and among TCs. RESULTS: The risk of dying at a TC in contrast to an NTH was higher among young adult males and cases admitted through the emergency department/room. In rural areas, fatality was higher among 25-44 year olds, Hispanics, uninsured patients, and cases admitted through transfer. In urban settings, fatality was higher among 18-24 year olds, patients covered by 'other' insurance, and cases admitted as severe emergencies. Increased mortality at Level I TCs occurred due to the transfer of patients from rural areas. Blacks and Hispanics in rural areas were more likely to die, while Hispanics had lower fatality in Level I TCs in urban areas. Survival time was longer for patients treated in urban TCs compared with rural TCs. CONCLUSION: In the absence of validated data about severity of cases and type of injury, and details about the treatment provided to trauma cases in this study, more investigation is needed into the case-mix of trauma patients admitted to TCs and NTHs. Further exploration is necessary for better co-ordination of the emergency care response to integrate NTHs within the trauma system and alleviate the stress placed on Level I TCs. Revisiting the transfer algorithms could improve clinical outcomes, particularly when TCs are closed due to diversion protocols.

Health care providers' assessments of the quality of advanced-cancer care in Latin American medical institutions: a comparison of predictors in five countries: Argentina, Brazil, Cuba, Mexico, and Peru.

This paper describes an innovative Pan-American survey on advanced-cancer care and examines the quality-of-care provided by Latin American institutions. A convenience sample of 777 physicians and nurses who treat cancer patients in Argentina, Brazil, Cuba, Mexico, and Peru were surveyed. Providers were identified through mass mailings, distribution at professional meetings and conferences, collaboration with regional institutions, professional organizations, and PAHO and online posting. Multiple linear regression analyses were conducted to identify predictors of quality-of-care assessments in each country. The five predictive models were subsequently compared descriptively. Higher access to care ratings and greater availability of end-of-life services corresponded with improved institutional quality-of-care ratings for all five countries. Barring respondents from Cuba, providers from the other four nations who practice in public institutions rated the quality of advanced-cancer care in their own institutions lower than those practicing in private hospitals or specialized cancer centers. Other institutional quality-of-care predictors included type of city, affordability-of-care ratings, availability of opioid analgesics, where patients die, barriers to cancer pain management, and the provider's specialty and gender. These findings highlight the need for providing accessible care and services to improve the quality of advanced-cancer care in Latin American institutions. Efforts should be aimed at improving the care offered in public institutions and addressing other types of disparities that may exist within countries by creating supportive and palliative cancer care programs that are accessible and affordable to those most in need.

Regionalized trauma care system in Texas: implications for redesigning trauma systems.

BACKGROUND: The aim of this investigation was to evaluate the theoretical framework of regionalized trauma care that places highest expertise at Level I and II Trauma Centers. MATERIAL/METHODS: To document appropriateness of regionalization the authors examined outcomes of all injured cases hospitalized over 2 years in trauma centers in Texas. The outcome measure was survival following an injury for cases that were treated in any trauma center. RESULTS: Survival was disproportionately lower at Level II and mostly Level I centers compared to centers with lower expertise. When adjusting for severity the difference in survival between centers was of smaller amplitude. Moreover, survival among the cases transferred to Level I and II trauma centers did not differ when adjusting for severity and mortality risk. Patients older than 45, of Hispanic origin, and with some type of insurance were less likely to survive at these centers. Lower survival was associated with shorter length of hospital stay and increased severity. CONCLUSIONS: The study raises the question whether regionalization in its current form is the appropriate framework for the organization of trauma care in Texas. Small variation in survival among trauma centers with highest expertise, indicate the need to revisit the entire concept of regionalized trauma care or particular elements of its structure. One solution suggested here is to have multiple centers with similar expertise at the core of the system acting as "Trauma Hospitals" which would connect with all the other hospitals in the region regardless of their expertise in an integrative model.

Predictors of nurses' acceptance of an intravenous catheter safety device.

BACKGROUND: It is important to determine the factors that predict whether nurses accept and use a new intravenous (IV) safety device because there are approximately 800,000 needlesticks per year with the risk of contracting a life-threatening bloodborne disease such as HIV or hepatitis C. OBJECTIVES: To determine the predictors of nurses' acceptance of the Protectiv Plus IV catheter safety needle device at a teaching hospital in Texas. METHOD: A one-time cross-sectional survey of nurses (N = 742) was conducted using a 34-item questionnaire. A framework was developed identifying organizational and individual predictors of acceptance. The three principal dimensions of acceptance were (a) satisfaction with the device, (b) extent to which the device is always used, and (c) nurse recommendations over other safety devices. Measurements included developing summary subscales for the variables of safety climate and acceptance. Descriptive statistics and multiple linear and logistic regression models were computed. RESULTS: The findings showed widespread acceptance of the device. Nurses who had adequate training and a positive institutional safety climate were more accepting (p