Use of cancer susceptibility testing among primary care physicians.

Primary care physicians (PCPs) are assuming greater roles in cancer risk assessment and susceptibility testing of patients. The objective of this study was to assess the beliefs and practices of PCPs relative to genetic susceptibility testing for cancer. A cross-sectional survey was mailed to 726 PCPs in community-based practices in southeastern Pennsylvania and southern New Jersey. Data were collected on physician background, cognitive and psychosocial factors, practice environment, and patient factors. The main outcome measure was physician self-reported recommendation or referral of patients for cancer genetic susceptibility testing in a 12-month period prior to the survey. Of those surveyed, 475 (65%) PCPs responded. Complete survey data were available for 433 PCPs. Multivariable analyses show that factors positively associated with PCP recommendation/referral included: patient inquiry about their need for genetic testing for cancer (p < 0.001); PCP belief that patient age is the best predictor of cancer risk (p = 0.01); PCP self-reported frequency of collecting patient diet information (p = 0.01) and medical history information (p = 0.01); and PCP participation in an integrated health system (p = 0.01). PCP use of cancer genetic susceptibility testing may be influenced by patient inquiry, provider beliefs about factors that affect cancer risk, provider collection of risk-assessment data, and provider practice environment.

Prenatal zidovudine use and congenital anomalies in a medicaid population.

OBJECTIVES: To examine the association of prescribed zidovudine (ZDV) during pregnancy with congenital anomalies in a population-based cohort. METHODS: Medicaid claims were used to assess prescribed ZDV and children's major congenital anomalies in 1932 liveborn deliveries from 1993 to 1996 to HIV-infected women in the state of New York (NYS), U.S.A. Prevalence of anomalies in the cohort was compared with that of a general NYS population. Within the cohort, adjusted odds of any anomaly were compared by receipt of ZDV and by trimester of first prescription. RESULTS: The adjusted prevalence of any anomaly in the study cohort was 2.76 times greater than in the general population (95% confidence interval [CI], 2.36-3. 17). Children of study women who were prescribed ZDV had increased adjusted odds of any anomaly (adjusted odds ratio [OR], 1.55; 95% CI, 1.01-2.29). Adjusted ORs (with CIs) by trimester of first prescription were 1.20 (0.58-2.51), 1.47 (0.85-2.55), and 1.84 (1. 04-3.25) for the first, second, and third trimesters, respectively. CONCLUSION: Children of HIV-infected women in this cohort had a greater prevalence of major anomalies than did the general NYS population. An increased risk of major anomalies was not evident for first trimester exposure when the association would have been most biologically plausible.

Improved birth outcomes among HIV-infected women with enhanced Medicaid prenatal care.

OBJECTIVES: This study evaluated the impact of enhanced prenatal care on the birth outcomes of HIV-infected women. METHODS: Medicaid claims files linked to vital statistics were analyzed for 1723 HIV-infected women delivering a live-born singleton from January 1993 to October 1995. Prenatal care program visits were indicated by rate codes. Logistic models controlling for demographic, substance use, and health care variables were used to assess the program's effect on preterm birth (less than 37 weeks) and low birthweight (less than 2500 g). RESULTS: Of the women included in the study, 75.3% participated in the prenatal care program. Adjusted program care odds were 0.58 (95% confidence interval [CI] = 0.42, 0.81) for preterm birth and 0.37 (95% CI = 0.24, 0.58) for low-birthweight deliveries in women without a usual source of prenatal care. Women with a usual source had lower odds of low-birthweight deliveries if they had more than 9 program visits. The effect of program participation persisted in sensitivity analyses that adjusted for an unmeasured confounder. CONCLUSIONS: A statewide prenatal care Medicaid program demonstrates significant reductions in the risk of adverse birth outcomes for HIV-infected women.

Sources of prenatal care data and their association with birth outcomes of HIV-infected women.

OBJECTIVES: Different sources of prenatal care data were used to examine the association between birth outcomes of HIV-infected women and the Adequacy of Prenatal Care Utilization (APNCU) index. METHODS: Adjusted odds ratios of birth outcomes for 1858 HIV-positive mothers were calculated for APNCU indexes on the basis of birth certificate data or 3 types of physician visits on Medicaid claims. RESULTS: Claims- and birth certificate-based APNCU indexes agreed poorly (kappa < 0.3). Only the broadest claims-based APNCU index had lower adjusted odds ratios for low birthweight (0.64; 95% confidence interval [CI] = 0.49, 0.84) and preterm birth (0.70; 95% CI = 0.54, 0.91). The birth certificate-based index had a reduced adjusted odds ratio (0.73; 95% CI = 0.56, 0.95) only for preterm birth. CONCLUSIONS: The association of birth outcomes and adequacy of prenatal care in this HIV-infected cohort differed significantly depending on the source of prenatal care data.

Frequency and predictors of medically attended injuries in HIV-infected children.

The extent to which medically attended injuries complicate the clinical course of HIV-infected (HIV+) children is unknown. In a cohort of HIV+ children delivered from 1985 to 1990 and aged less than 60 months, we determined medically attended injuries per 100 child-years, Injury Severity Scores (ISS), and predictors of medically attended injuries by using New York State Medicaid claims from 1986 to 1992 linked to birth certificates. Injury rates and ISS were compared to those of a population of black, inner city children aged less than 60 months from emergency room records. HIV+ children had slightly more injuries (19.3 vs. 16.8/100 child-years) but similar ISS (2.4 vs. 2.3). Predictors of injuries in HIV+ children included younger maternal age (24/100 child-years, p = 0.008) and delivery outside of New York City (29/100 child-years, p = 0.02). Illicit drug use and alcohol use were associated with greater ISS while cocaine use was associated with a higher rate of possibly intentional injuries. Medically attended injuries affected one in five HIV+ children in our cohort annually, slightly more than the comparison population. Specific maternal and birth characteristics such as substance abuse and younger age at delivery may help target at-risk children.

Improved birth outcomes associated with enhanced Medicaid prenatal care in drug-using women infected with the human immunodeficiency virus.

OBJECTIVE: To evaluate the effectiveness of an intervention designed to enhance Medicaid prenatal care in improving birth outcomes of drug-using women infected with the human immunodeficiency virus (HIV). METHODS: Medicaid and vital statistics records were linked for 353 HIV-infected drug-using women delivering in 1993 and 1994 while enrolled in New York State Medicaid. Of these, 68% were treated by providers participating in the Prenatal Care Assistance Program, designed to provide case management, improved continuity, referral services, and behavioral risk reduction counseling. In a series of logistic models, we estimated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of low birth weight (less than 2500 g) and preterm delivery (before 37 weeks), comparing women using and not using the program. RESULTS: Women using the Prenatal Care Assistance Program were significantly less likely, after adjustments were made for maternal characteristics, to have low birth weight infants and preterm deliveries (OR 0.52, 95% CI 0.31, 0.89; and OR 0.57, 95% CI 0.34, 0.97, respectively). Adding measures of greater adequacy and continuity of prenatal care to the models explained just over 20% of the Prenatal Care Assistance Program's protective effect. The addition of maternal high-risk behavior, HIV-focused care, and drug use treatment variables altered program effect estimates less profoundly (together accounting for 4 and 9% of the program's protection against low birth weight and preterm delivery, respectively). CONCLUSION: The Prenatal Care Assistance Program appeared to be successful in reducing the incidence of low birth weight and preterm delivery in this high-risk population. The program's success can be attributed, in part, to increased adequacy and continuity of prenatal care and, to a lesser extent, to more frequent receipt of special services and reduced maternal high-risk behaviors.

Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia.

OBJECTIVE: To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis. DESIGN: Nonconcurrent prospective study. SETTING: New York State Medicaid Program. PARTICIPANTS: Medicaid enrollees diagnosed with AIDS in 1990-1992. MEASUREMENTS AND MAIN RESULTS: We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP. CONCLUSIONS: PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features.

Clinic services for persons with AIDS. Experience in a high-prevalence state.

OBJECTIVE: To profile characteristics of clinics caring for persons with advanced HIV infection. DESIGN AND SETTING: Survey of clinic directors in New York State. PARTICIPANTS: Newly diagnosed Medicaid-enrolled AIDS patients in New York state in federal fiscal years 1987-1992 (n = 6,184) managed by 62 HIV specialty, 53 hospital-based general medicine/primary care, 36 community-based primary care, and 28 other clinics. MEASUREMENTS AND MAIN RESULTS: Telephone survey about clinic hours, emphasis on HIV, staffing, procedures, and directors' rating of care. Estimates of the number of newly diagnosed, Medicaid-enrolled AIDS patients treated in surveyed clinics were obtained from claims data. We found that community-based clinics were significantly more likely to have longer hours, a physician on call, or to accommodate unscheduled care than were hospital-based general medicine/ primary care or other types of clinics. Compared with HIV specialty clinics, general medicine/primary care clinics were less likely to have HIV-specific care attributes such as a director of HIV care (98% vs 72%), multidisciplinary conferences on HIV care (83% vs 32%), or a standard initial HIV workup (90% vs 70%). Of general medicine/primary care clinics, most (83%) were staffed by residents and fellows compared with only 68% of HIV or 25% of community-based clinics (p < .001). General medicine/primary care clinics were less likely than community-based clinics to perform Pap smears (75% vs 94%) or to have case managers on payroll (21% vs 81%). CONCLUSIONS: In this sample of clinics, hospital-based general medicine/primary care clinics managing the care of Medicaid enrollees with AIDS appeared to have more limited hours and availability of specific services than HIV specialty or community-based clinics.

Prenatal care of HIV-infected women: analysis of a large New York State cohort.

We examined the effect of methadone treatment, duration of Medicaid enrollment during pregnancy, and other maternal characteristics on receipt of prenatal care by 2,254 women infected with human immunodeficiency virus (HIV) delivering a singleton in New York state from 1985 through 1990. Data were obtained from the New York State Medicaid HIV/AIDS Research Data Base and vital statistics records. Adequacy of the number of prenatal visits reported by the mother on vital statistics records was assessed with use of the Kessner Index, which adjusts for gestational age at delivery. Too few visits were reported by 65% of the study population. Illicit drug users had higher odds of having too few visits [1.64, 95% confidence interval (CI) 1.24-2.17] than methadone-treated women but the odds were similar for non-drug users and methadone-treated women (0.79, 95% CI 0.60-1.25). Women with brief Medicaid enrollment (< or = 25% of pregnancy) had 45% higher odds of having too few visits than did longer enrollees. Treatment for drug addiction and longer Medicaid enrollment during pregnancy may offer important interventions to increase prenatal care of HIV-infected women. Approaches to increase prenatal care of HIV-infected women are especially important given trials showing a reduction in vertical transmission from zidovudine treatment during pregnancy.