Assessing the Feasibility of Partnering with a Home Visiting Program for Early Childhood Obesity Prevention.

PURPOSE: Little empirical data exists evaluating the feasibility of partnering with established home visiting programs to implement early childhood obesity prevention programs, despite the recommendation to do so. To inform this gap, we evaluated the feasibility of collecting anthropometric measurements of children by home visitors across multiple sites, and the alignment of these measurements with children in need, including with adverse family experiences (AFEs) given emerging evidence suggests an association with childhood obesity. DESCRIPTION: Our proof-of-concept study included primary data collection of child anthropometric measurements through an established home visiting program in four states. This sample included 248 children ages 6 months to 5 years. ASSESSMENT: In the sample, 37.1% of the children had overweight or obesity, 50% were female, 64.2% Hispanic/Latinx, 15.8% non-Hispanic Black, and 42.3% from rural/small towns. Households included substantial needs: 87.1% were low income, 73.8% low education, and 59.3% underemployment. Regarding AFEs, 38.3% of the children had at least one, with the most common being mothers who were treated violently. A multivariable model revealed community type, not AFEs, was significantly associated with overweight/obesity status, suggesting children in suburban and especially rural/small town residences (odds ratio 5.11; 95% CI [1.59, 16.39]) could be priority populations for childhood obesity prevention programs. CONCLUSION: Findings of this multi-site study inform the feasibility of partnering with home visiting programs to reach and measure a diverse sample of children and families in need of childhood obesity prevention.

Prevalence of Poor Mental Health Days and Adverse Childhood Experience Reporting in U.S. Adults Before and After COVID-19.

This is the first study of US adults to examine change in the prevalence of psychological burden (i.e., self-reported poor mental health days in the past 30 days, and ACEs recollections) before compared to after COVID-19 started. We analyzed the prevalence of self-reported poor mental health days, and ACEs recollections from 17 states using the Behavioral Risk Factor Surveillance System. Adjusted models identified an increase in prevalence from before compared to after COVID-19 onset in those married or partnered reporting 48% more poor mental health days in the past 30 days; persons of color reporting living with anyone with mental illness during childhood by 73% and reporting more ACEs by 35%; those employed or self-employed reporting childhood sexual abuse by 45%. This ecological-level analysis revealed population-level changes in psychological well-being reporting of U.S. adults from before compared to after the pandemic onset.

Disparities in Text Messaging Interventions to Improve Diabetes Management in the United States.

Substantial progress has been made in the development of evidence-based interventions to facilitate the management of type 2 diabetes. The increase in ownership of mobile phones has made short messaging services (SMS, or text messaging) a feasible way to enhance information delivery. The goals of this study were to 1) summarize characteristics of diabetes SMS interventions implemented in the United States and 2) identify the extent to which disadvantaged populations are represented in SMS-based diabetes management intervention studies. We conducted a literature search to identify published studies of type 2 diabetes self-management SMS interventions conducted with adults in the United States. Of the 792 articles retrieved, only 9 met inclusion criteria. We systematically extracted data on the theoretical basis, recruitment, incentives, inclusion/exclusion criteria, strategies toward ensuring a racially/ethnically or income-diverse sample, text message delivery, and study duration. Sixty-three percent of the participants across the nine studies were non-white. Only two studies reported participants' education level, and four captured non-English-speaking status. Interventions varied in offering one-way, two-way, or a combination of messaging strategies. Five studies did not describe cultural adaptations or report results separately for different cultural groups. None of the studies provided cell phones, and not having texting capability was an exclusion criterion for six studies. There is a dearth of published research on type 2 diabetes management interventions using text messaging among racially/ethnically or income-diverse populations. Future interventions should be better tailored to these target populations and include the collection of complete sociodemographic data and cell phone/smartphone availability, thereby ensuring cultural appropriateness.

Collecting Early Childhood Obesity Measurements Through a Home Visiting Program: A Proof-of-Concept Study.

Community-based home visiting programs are recommended vehicles for early life-course interventions to prevent childhood obesity. We developed and implemented a proof-of-concept protocol for collecting child weight and length or height data for children aged 6 months to 5 years through Parents as Teachers (PAT) affiliates that were geographically dispersed throughout the United States. We implemented our protocol with 1 affiliate in each of 4 states. We assessed formative measures of the implementation from parent educators and site leaders and reviewed delivery process measures. Findings suggest that collecting data on child measurements through an existing home visiting program is 1) feasible (91% of estimated measurements achieved); 2) does not require much time (median, 0.5 hours spent per child); 3) is a positive experience for families (71% of parent educators indicated that families enjoyed the experience); and 4) is fairly accurate (82% of collected data met eligibility and quality standards).

A Strategy for Addressing Population Health Management.

CONTEXT: Population health management in the era of the Affordable Care Act focuses on identifying needs of health care service areas for targeted strategies. The United States has a "health disadvantage" compared with peer countries, particularly regarding obesity and women's life expectancy, while having high rates of mammography screening. Emphasizing lifestyle factors is a strategy to reduce one's risk of obesity and heart disease, as well as some breast cancers. OBJECTIVE: We explored perceptions of the risk of female population-based breast cancer mortality compared with heart disease mortality; perceived likelihood of developing breast cancer; and recognition of the association between modifiable lifestyle factors and breast cancer risk. DESIGN: Cross-sectional online survey. SETTING: Service area of one mid-Missouri health care system. PARTICIPANTS: Female US residents ages 35 to 49 years who did not have a personal history of any cancer. RESULTS: Minority women and women with a college education or less had greater odds of reporting that breast cancer, rather than heart disease, would cause more deaths in women this year. Women who had ever had a mammogram had greater odds of reporting a moderate/high compared with low likelihood of developing breast cancer. Women with less than a college education had greater odds of not knowing of any lifestyle behaviors or reporting only clinical behaviors related to reducing one's risk of breast cancer. CONCLUSIONS: The present study illuminates areas of lagging information dissemination that may be used for targeted strategies for population health management in the era of the Affordable Care Act, that of bridging healthy lifestyle strategies for heart health with messages for breast health.

Interprofessional perspectives on ACEs: Results from a statewide interprofessional training program.

BACKGROUND: Adverse childhood experiences (ACEs) are pervasive and well-recognized as having lasting deleterious effects on the physical and mental health of those who experience them, particularly with accumulated exposure. OBJECTIVE: This study seeks to identify the perspectives of interprofessional health providers on their personal and professional experiences with ACEs, ACEs screening, how to work with people with ACEs, and make recommendations for the field. PARTICIPANTS AND SETTING: Sixty-two health professionals and PhD students who completed at least one module of an online course and at least one of the accompanying discussion board sub-prompts. METHODS: Responses to five course discussion board assignments, each with multiple sub-prompts, were coded to determine and refine major themes and merged with demographic and other background data. From the 561 responses, six themes were identified and used to analyze response patterns. RESULTS: Twenty-nine percent of responses reflected a macro perspective on ACEs; 29 % of responses reflected workplace experiences; 28 % of responses reflected ACEs complexity, 8 % of responses reflected a personal relationship to ACEs, 3 % reflected perspectives on resilience; and 3 % were related to the course. Participants communicated complex understandings of ACEs, demonstrating the relevance and importance of the topic for public health training. CONCLUSIONS: Integrating ACEs training into the practice setting provides opportunities to improve the health and lives of those suffering from ACEs, especially when incorporating provider voice and perspectives.

Reimagining the university's role in the health and well-being of the people it serves.

Academic medical centers and university extension programs remain underdeveloped collaborators, despite the complementary objectives between translational science and extension. This case study details the creation of a nationally unique interprofessional organizational structure between the University of Missouri (MU) Office of Extension and Engagement (MU Extension) and the MU School of Medicine to accelerate statewide reach of research and education discoveries using high-touch community health approaches. This article describes specific strategies used to systematically plan for: 1) creation and operation of the new structure, 2) routinization and institutionalizing the work, and 3) sustainability. We further outline challenges and next steps. The development of the backbone organization office of Health Outreach Policy and Education (HOPE) brings together the interprofessional expertise of five units with a common agenda to advance mutually reinforcing activities. HOPE is poised to make significant contributions to amplify MU's land grant mission, garner additional grant funding, and advance the health of Missourians.

Research recruitment using Facebook advertising: big potential, big challenges.

To our knowledge, ours is the first study to report on Facebook advertising as an exclusive mechanism for recruiting women ages 35-49 years residing in the USA into a health-related research study. We directed our survey to women ages 35-49 years who resided in the USA exclusively using three Facebook advertisements. Women were then redirected to our survey site. There were 20,568,960 women on Facebook that met the eligibility criteria. The three ads resulted in 899,998 impressions with a reach of 374,225 women. Of the women reached, 280 women (0.075 %) clicked the ad. Of the women who clicked the ad, nine women (3.2 %) proceeded past the introductory page. Social networking, and in particular Facebook, is an innovative venue for recruiting participants for research studies. Challenges include developing an ad to foster interest without biasing the sample, and motivating women who click the ad to complete the survey. There is still much to learn about this potential method of recruitment.

Are mammography recommendations in women younger than 40 related to increased risk?

Our objective was to examine the association between self-reported breast cancer risk factors and reported physician recommendations for mammography among women younger than 40. This study uses the 2005 National Health Interview Survey (NHIS) and includes 2,703 women ages 30-39 who reported having seen a doctor in the past 12 months. The NHIS is a population-based, cross-sectional survey of adult respondents in the United States. Overall, 19.0% of these women reported a recent mammography recommendation. Among women reporting no prior mammogram, women ages 30-34 with risk factors for breast cancer were more likely to report a recent mammogram recommendation than women without risk factors. There was no such association for women ages 35-39. Among women who reported a prior mammogram, risk factors were not associated with a recommendation for mammography; there was an association with age and recent clinical breast examination. Despite a lack of evidence-based guidelines for women under 40 years of age, these data suggest some younger women are being recommended for early mammography without indication. The relative benefits and harms of recommending mammography in this age group need further examination.

Are there racial/ethnic disparities among women younger than 40 undergoing mammography?

While the probability of a woman developing invasive breast cancer at age <40 is low (<1%), mammography use reported among younger women (age <40) is substantial, and varies by race/ethnicity. Little detail is known about mammography use among women aged <40, particularly by race/ethnicity. We describe racial/ethnic differences in: (1) mammography indication after considering underlying risk factors (breast symptoms and family history); (2) follow-up recommendations, and (3) mammography outcomes for first mammograms in women aged <40. These 1996-2005 Breast Cancer Surveillance Consortium data are prospectively pooled from seven U.S. mammography registries. Our community-based sample included 99,615 women aged 18-39 who self-reported race/ethnicity and presented for a first mammogram (screening or diagnostic) with no history of breast cancer. Multivariable analyses controlled for registry site, age, family history of breast cancer, symptoms, and exam year. Overall, 73.6% of the women in our sample were seen for a screening mammogram. Following screening mammography, African American (AA) women were more likely than white women to be recommended for additional workup [relative risk (RR): 1.15 (95% CI: 1.07-1.23)]. Following diagnostic mammography, AA [RR: 1.30 (95% CI: 1.17-1.44)] and Asian [RR: 1.44 (95% CI: 1.26-1.64)] women were more likely to be recommended for biopsy, fine-needle aspiration, or surgical consultation. Depending on race/ethnicity, and considering the rate of true positive to total first screening mammograms of younger women, a women has a likelihood of a true positive of 1 in 363-1,122; she has a likelihood of a false positive of 1 in 7-10. This study of community-based practice found racial/ethnic variability in mammography indication, recommendations, and outcomes among women undergoing first mammography before 40. These findings highlight important areas for future research to understand the motivating factors for these practice patterns and the implications of early mammography use.

Racial and ethnic differences in mammography use among U.S. women younger than age 40.

OBJECTIVE: Evidence-based recommendations for routine breast cancer screening suggest that women begin mammography at age 40, although some women receive a mammogram before that age. Little is known about mammography use among younger women, especially with respect to race and ethnicity. METHODS: We used data from the 2005 National Health Interview Survey to examine racial/ethnic differences in mammography use among U.S. women ages 30-39. We examined descriptive characteristics of women who reported ever having a mammogram, and used logistic regression to estimate associations between race/ethnicity and mammography use among women at average risk for breast cancer. RESULTS: Our sample comprised 3,098 women (18% Hispanic, 13% non-Hispanic [NH] black, 69% NH white), of whom 29% reported having ever had a mammogram. NH black women were more likely than NH white women to report ever having a mammogram and receiving multiple mammograms before age 40 among women of average risk. Patterns of mammography use for Hispanic women compared to NH white women varied. CONCLUSION: Findings suggest differential utilization of mammograms by race/ethnicity among women outside current recommendations and of average risk. Future studies should examine the role of practice patterns and patient-provider communication.

Kombucha: a systematic review of the empirical evidence of human health benefit.

PURPOSE: Kombucha tea, a fermented beverage, has recently become popular in the United States as part of the functional food movement. This popularity is likely driven by its touted health benefits, coupled with the recent scientific movement investigating the role of the microbiome on human health. The purpose of this systematic review is to describe the literature related to empirical health benefits of kombucha as identified from human subjects research. METHODS: In July 2018, we searched the term "kombucha" for all document types in the following databases across all available years: PubMed, Scopus, and Ovid. To identify federal research grants related to kombucha, we searched the National Institutes of Health Research Portfolio Online Reporting Tools. Finally, to identify ongoing human subjects research, we searched clinicaltrials.gov and clinicaltrialsregister.eu. We reviewed a total of 310 articles. RESULTS: We found one study reporting the results of empirical research on kombucha in human subjects. We found no results for kombucha in Research Portfolio Online Reporting Tools, clinicaltrials.gov, or clinicaltrialsregister.eu. CONCLUSIONS: The nonhuman subjects literature claims numerous health benefits of kombucha; it is critical that these assertions are tested in human clinical trials. Research opportunities are discussed.

The economic case for US hospitals to revise their approach to heart failure readmission reduction.

To support hospital decision makers in their effort to reduce readmissions, the authors of this perspective present employer self-insurance as a potential incentive strategy, in particular for heart failure (HF). In 2010, US health reform identified hospital readmission as a key area for improving care coordination and achieving potential healthcare savings, and enacted the Hospital Readmissions Reduction Program (HRRP). In 2012, the Centers for Medicare and Medicaid Services (CMS) started the implementation of the HRRP by penalizing hospitals with excess 30-day readmission rates. The HRRP targets certain conditions, including HF, which is among the most expensive conditions treated in US hospitals. HF has the highest readmission rate for patients aged 65 and above, and its prevalence is expected to rise to over 8 million people by 2030 due to the aging population. Although the HRRP has been associated with reduced readmission rates, the rate of reduction has slowed. Furthermore, the HRRP may have alarming unintended consequences, such as possible increased mortality among HF patients. As a result, a critical analysis of financial incentives is needed to re-energize these efforts. One opportunity to incentivize readmission reduction is through employer self-insurance. More than half of colleges and universities self-insure the health care coverage they offer to their employees. With these self-insured plans, a hospital could be rewarded through shared savings with a university for readmission reduction. This perspective proposes that the economic case for a hospital to invest in readmission reduction is stronger when a hospital is a part of a self-insured university.

The Evidence Base for the Maternal, Infant, and Early Childhood Home Visiting Program Constructs.

OBJECTIVES: The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program requires grantees to demonstrate program improvement as a condition of funding. The MIECHV program monitors grantee progress in federally mandated conceptual areas (ie, benchmarks) that are further subcategorized into related sub-areas or constructs (eg, breastfeeding). Each construct has an associated performance measure that helps MIECHV collect data on program implementation and performance. In 2016, MIECHV modified the constructs and associated performance measures required of grantees. Our objective was to identify whether the constructs were supported by the home visiting literature. METHODS: We conducted an evaluation of one of the MIECHV program's benchmarks (Benchmark 1: Maternal and Newborn Health) for alignment of the Benchmark 1 constructs (preterm birth, breastfeeding, depression screening, well-child visit, postpartum care, and tobacco cessation referrals) with home visiting evidence. In March 2016, we searched the Home Visiting Evidence of Effectiveness database for all publicly available articles on studies conducted in the United States to determine how well the study findings aligned with the MIECHV program constructs. RESULTS: Of 59 articles reviewed, only 3 of the 6 MIECHV constructs-preterm birth, breastfeeding, and well-child visits-were supported by home visiting evidence. CONCLUSIONS: This evaluation highlights a limited evidence base for the MIECHV Benchmark 1 constructs and a need to clarify other criteria, beyond evidence, used to choose constructs and associated performance measures. One implication of not having evidence-based performance measures is a lack of confidence that the program will drive positive outcomes. If performance measures are not evidence based, it is difficult to attribute positive outcomes to the home visiting services.

US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients.

BACKGROUND: Patients are often not told about harmful medical errors. The malpractice environment is considered a major determinant of physicians' willingness to disclose errors to patients. Yet, little is known about the malpractice environment's actual effect on physicians' error disclosure attitudes and experiences. METHODS: Mailed survey of 2637 physicians (62.9% response rate) in the United States (Missouri and Washington) and Canada, countries with different malpractice environments. RESULTS: Physicians' error disclosure attitudes and experiences were similar across country and specialty. Of the physicians, 64% agreed that errors are a serious problem. However, 50% disagreed that errors are usually caused by system failures. Ninety-eight percent endorsed disclosing serious errors to patients and 78% supported disclosing minor errors; 74% thought disclosing a serious error would be very difficult. Fifty-eight percent had disclosed a serious error to a patient, and 85% were satisfied with the disclosure, and 66% agreed that disclosing a serious error reduces malpractice risk. Respondents' estimates of the probability of lawsuits were not associated with their support for disclosure. The belief that disclosure makes patients less likely to sue (odds ratio, 1.58), not being in private practice (odds ratio, 1.47), being Canadian (odds ratio, 1.43), and being a surgeon (odds ratio, 1.26) were independently associated with higher support for disclosing serious errors. CONCLUSIONS: US and Canadian physicians' error disclosure attitudes and experiences are similar despite different malpractice environments, and reveal mixed feelings about disclosing errors to patients. The medical profession should address the barriers to transparency within the culture of medical and surgical specialties.

A comparison of the health status and behavioral risk factors among English-speaking Hispanics and non-Hispanic Blacks and Whites in Missouri.

OBJECTIVES: The study objectives were to estimate the prevalence of chronic diseases and other health indicators for Hispanics in Missouri, and to compare their prevalence estimates with other racial/ethnic groups. DESIGN / SETTING / PARTICIPANTS: This study, conducted in public health and academic settings, used combined data from the 2002 and 2003 Missouri Behavioral Risk Factor Surveillance System and the 2003 Missouri County-Level Study. Data were post-stratified with Hispanic ethnicity as a separate group. MAIN OUTCOME MEASURES: Twenty health indicators were compared. Logistic regression was used to control for sociodemographic characteristics. RESULTS: Overall, 21.7% (95% confidence interval [CI] 13.4-30.0) of Hispanics, 19.8% (95% CI 14.4-25.2%) of non-Hispanic Blacks, and 12.2% (95% CI 11.2-13.1%) of non-Hispanic Whites had no insurance coverage. Hispanics were significantly less likely to report poor or fair health (12.1%, 95% CI 7.5-16.7%) than non-Hispanic Blacks (21.6%, 95% CI 17.2-26.0%), and less likely to report activity limitation (12.9%, 95% CI 8.0-17.9%) than non-Hispanic Whites (20.2%, 95% CI 19.1-21.2%). Controlling for sociodemographic characteristics, Hispanics had greater physician-diagnosed diabetes (OR = 2.0, 95% CI 1.0-3.3%) and Hispanics aged > or = 50 were less likely to have no sigmoidoscopy or colonoscopy in the past five years (OR = 0.5, 95% CI 0.2-1.0%) compared to non-Hispanic Whites. CONCLUSIONS: Other than lower healthcare coverage and diabetes status, the health indicators for English-speaking Hispanics were similar to, or better than, non-Hispanic Blacks and Whites. However, these data may not represent all Hispanics in Missouri since health status between English-speaking and non-English speaking Hispanics may differ significantly.

Diabetes and tooth loss in a national sample of dentate adults reporting annual dental visits.

INTRODUCTION: Periodontal disease has been associated with tooth loss and reported as more prevalent among people with diabetes than among those without diabetes. Having an annual dental examination is a national goal of Healthy People 2010. Our objective was to examine whether an association exists between diabetes and tooth loss among a population reporting an annual dental visit. METHODS: We used data from the 2004 Behavioral Risk Factor Surveillance System to examine the association between self-reported diabetes and tooth removal due to decay or periodontal disease among 155,280 respondents reporting a dental visit within the past year. We calculated prevalence estimates, odds ratios, and 95% confidence intervals. Multiple logistic regression allowed for adjustment. RESULTS: The overall prevalence of tooth removal among the people in the study was 38.3%. People with diabetes had a significantly higher prevalence of tooth removal. In a multivariable model adjusting for selected covariates, respondents with diabetes were 1.46 times as likely (95% CI, 1.30-1.64) to have at least one tooth removed than respondents without diabetes. A stronger association between diabetes and tooth loss was observed among people in the younger age groups than among those in the older age groups. CONCLUSION: Even among people reporting a recent dental visit, diabetes was independently associated with tooth loss. Multidisciplinary efforts are needed to raise awareness of the risk of tooth loss among younger people with diabetes. Good oral hygiene as well as annual dental examinations are important for preventing tooth loss.

Building and launching an online quality improvement information exchange for home visiting programs in Missouri.

Continuous quality improvement initiatives (CQII) in home visiting programs have traditionally occurred within a local implementing agency (LIA), parent organization, or funding provision. In Missouri, certain LIAs participate in the Missouri Maternal, Infant, and Early Childhood Home Visiting program (MIECHV). Their CQII activities and the coordination of CQI efforts across agencies are limited to quarterly meetings to discuss barriers to service delivery and newsletters. Their designed CQI process does not include evaluation of program fidelity or assessment nor supports to assist with identifying and prioritizing areas where improvement is needed. Therefore, much of LIA CQII are often lost to the benefit of external agencies facing similar challenges. We developed a virtual environment, the Missouri MIECHV Gateway, for CQII activities. The Gateway promotes and supports quality improvement for LIAs while aligning stakeholders from seven home visiting LIAs. Development of the Gateway environment aims to complement the existing MIECHV CQI framework by: 1) adding CQI elements that are missing or ineffective, 2) adding elements for CQI identification and program evaluation, and 3) offering LIAs a network to share CQI experiences and collaborate at a distance. This web-based environment allows LIA personnel to identify program activities in need of quality improvement, and guides the planning, implementation, and evaluation of CQII. In addition, the Gateway standardizes quality improvement training, collates overlapping resources, and supports knowledge translation, thus aimed to improve capacity for measurable change in organizational initiatives. This interactive web-based portal provides the infrastructure to virtually connect and engage LIAs in CQI and stimulate sharing of ideas and best practices. This article describes the characteristics, development, build, and launch of this quality improvement practice exchange virtual environment and present results of three usability pilot tests and the site launch. Briefly, prior to deployment to 58 users, usability pilot testing of the site occurred in three stages, to three defined groups. Pilot testing results were overall positive, desirable, and vital to improving the site prior to the full-launch. The majority of reviewers stated they would access and use the learning materials (87%), use the site for completing CQII (80%), and reported that the site will benefit their work teams in addressing agency challenges (66%). The majority of reviewers also approved of the developed fidelity assessment: as, easy to use (79%), having a clear purpose (86%), providing value in self-identification of CQII (75%), and recommendations were appropriate (79%). The System Usability Scale (SUS) score increased (10%) between pilot groups 2 and 3, with a mean SUS score of 71.6, above the U.S. average of 68. The site launched to 60 invited users; the majority (67%) adopted and used the site. Site stability was remarkable (6 total minutes of downtime). The site averaged 29 page views per day.

Racial disparities in diabetes-related preventive care: results from the Missouri Behavioral Risk Factor Surveillance System.

INTRODUCTION: Racial disparities exist in the rates of diabetes complications in the United States and in the state of Missouri. It is unclear to what degree such disparities involve diabetes-related preventive care. We sought evidence for racial disparities in diabetes-related preventive care between non-Hispanic blacks and whites in Missouri. METHODS: We analyzed data from the Missouri Behavioral Risk Factor Surveillance System from 1994 through 2002. This state-specific survey is conducted annually among a representative sample of Missourians. We examined data from 842 Missourians who reported a diagnosis of type 1 or type 2 diabetes and who had consulted a health professional in the 12 months before they were interviewed. We analyzed reported receipt of glycosylated hemoglobin testing, foot examinations, and dilated eye examinations in the year before interview. RESULTS: Non-Hispanic blacks were significantly less likely than whites to report having had glycosylated hemoglobin testing (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.22-0.99) but more likely to report having received foot examinations (OR, 1.99; 95% CI, 1.21-2.39). There was no difference between blacks and whites in the probability of dilated eye examinations (OR, 1.49; 95% CI, 0.94-2.36). CONCLUSION: Compared with whites, non-Hispanic blacks in Missouri receive adequate screening for diabetic complications but not for glycemic control. Further studies are needed to investigate whether these disparities are linked to differences in the rate of diabetes complications in Missouri.