Consented testing of newborns and childbearing women for human immunodeficiency virus through a newborn metabolic screening program.

OBJECTIVE: In this program a postpartum woman could consent to receive her newborn's human immunodeficiency virus test result from the New York State Newborn Screening Program. STUDY DESIGN: By state regulation each postpartum woman was counseled and offered her newborn's human immunodeficiency virus test result. With the mother's consent, newborn human immunodeficiency virus antibody test results from the Newborn Screening Program were sent to the baby's pediatrician; otherwise, test results were blinded. Data were analyzed for births from August 1, 1996, to January 31, 1997. RESULTS: Overall, 92.5% of women offered newborn human immunodeficiency virus testing consented to receive the result. Among 444 human immunodeficiency virus-positive women offered newborn testing, consented testing resulted in a 21.4% increase in knowledge of human immunodeficiency virus status from 72.3% (n = 321) at delivery to 93.7% (n = 416) after newborn testing; 6.3% (n = 28) of human immunodeficiency virus-positive women delivered of infants who did not consent apparently remained unaware of their human immunodeficiency virus status. CONCLUSION: Combined prenatal and consented newborn testing identified 94% of human immunodeficiency virus-positive mothers and exposed newborns, allowing early entry into care. Such testing may provide an opportunity for women not previously tested for the human immunodeficiency virus to learn their status but is not a substitute for universal prenatal human immunodeficiency virus counseling and consented human immunodeficiency virus testing.

Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery.

OBJECTIVE: The study sought to determine if there were race/ethnicity or gender differences in access to coronary artery bypass graft (CABG) surgery among patients who have been designated as appropriate and as necessary for that surgery according to the RAND methodology. METHODS: RAND appropriateness and necessity criteria were used to identify a race/gender stratified sample of postangiography patients who would benefit from coronary artery bypass graft surgery. These patients were tracked for 3 months to determine if they had undergone coronary artery bypass graft surgery in New York State. Subjects were a total of 1,261 postangiography patients in eight New York hospitals in 1994 to 1996. Measures included percentages of patients for whom coronary artery bypass graft surgery was appropriate and necessary undergoing surgery by race/ethnicity and gender, as well as multivariate odds ratios for race/ethnicity and gender. RESULTS: After controlling for age, payer, number of vessels diseased, and presence of left main disease, African-American and Hispanic patients were found to be significantly less likely to undergo coronary artery bypass graft surgery than white non-Hispanic patients (respective odds ratios 0.64 and 0.60). When "necessity" was used as a criterion instead of "appropriateness," significant differences in access for African-American patients remained. The gatekeeper physician recommended surgery only 10% of the time that patients did not undergo "appropriate" coronary artery bypass graft surgery, and this percentage did not vary significantly by race/ethnicity or gender of the patient. CONCLUSIONS: Even after controlling for appropriateness and necessity for coronary artery bypass graft surgery in a prospective study, African-American patients had significant access problems in obtaining coronary artery bypass graft surgery. These problems appeared not to be related to patient refusals.

Improving urban health.

New York's public health priorities initiative, Communities Working Together for a Healthier New York, creates a framework for communities, including urban areas, to identify and address their most pressing public health problems. It is both a call to action and a guide for the state's communities. The priorities identified in this initiative were the product of extensive public input across the state. Interestingly, the priorities identified by rural counties were consistent with those identified in the New York City workshop. To a great extent, urban and rural dwellers have the same health problems, such as teenage pregnancy, substance abuse, and tobacco use, although to different degrees. Accordingly, we need to recognize that we are a global society, in which the line separating urban and rural has thinned, if not disappeared. Improving health status in our communities, whether urban or rural, requires broad-based collaboration. It requires setting special interests aside and focusing on the good of the whole community. It requires sharing resources and expertise, as was done in the asthma study. By developing a shared vision of what our health priorities are, by forming partnerships in our communities to address them, and by employing the use of effective and innovative interventions, we will improve health status in our communities.

Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?

BACKGROUND AND OBJECTIVE: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals. METHODS: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology. RESULTS: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat." CONCLUSIONS: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.

Coronary artery bypass graft surgery in Ontario and New York State: which rate is right? Steering Committee of the Cardiac Care Network of Ontario.

BACKGROUND: Previous studies have shown that the rate of coronary artery bypass graft (CABG) surgery is much higher in New York State than in Ontario. OBJECTIVE: To compare the service context and clinical characteristics of patients having CABG surgery in New York and Ontario. DESIGN: Retrospective analysis of data from cardiac surgery registries in New York and Ontario. PATIENTS: All 16,690 patients in New York and 5517 patients in Ontario who had isolated CABG surgery in 1993. MEASUREMENTS: Clinical characteristics of patients having CABG surgery and rates of CABG surgery by coronary anatomy. RESULTS: The overall age-adjusted rate of isolated CABG surgery was 1.79 times (95% CI, 1.74 to 1.85) greater in New York than in Ontario. Patients who had CABG surgery in New York were more likely to be elderly and female and to have recently had myocardial infarction (P < 0.001), whereas patients who had CABG surgery in Ontario were more likely to have had left ventricular dysfunction and severe coronary artery disease (two-vessel disease with proximal left anterior descending disease, three-vessel disease, or left main disease) (P < 0.001). The relative rate of CABG surgery for left main disease was 2.53 times (CI, 2.35 to 2.73) greater in New York than in Ontario but was 8.97 times (CI, 8.01 to 10.06) greater for patients with limited coronary artery disease (one-vessel or two-vessel disease without proximal left anterior descending disease). CONCLUSIONS: The higher rates of CABG surgery in New York are associated with higher rates of CABG surgery among the elderly, women, and patients who recently had myocardial infarction. Potential underservicing in Ontario is suggested by a lower rate of CABG surgery for left main disease; however, the higher rate of CABG surgery in New York is also associated with a strikingly higher rate of surgery in patients with limited coronary disease. Such trade-offs highlight the difficulty of defining an optimal rate of CABG surgery.

Public release of cardiac surgery outcomes data in New York: what do New York state cardiologists think of it?

BACKGROUND AND OBJECTIVE: Since 1990, risk-adjusted outcomes for patients undergoing coronary artery bypass graft surgery in New York state have been released to the public. The purpose of this study was to assess the extent to which referring cardiologists share these data with patients and use these data to make referrals. METHODS: A survey questionnaire was sent to all cardiologists in New York in the New York State Chapter of the American College of Cardiology. RESULTS: Four hundred fifty cardiologists responded to the survey. Most (94%) found the report "easy to read." A majority (67%) found the report to be "very accurate" or "somewhat accurate" in capturing differences in the performance of cardiac surgeons, whereas 33% found it to be "not at all accurate." Twenty-two percent reported that they "routinely discuss the reports with their patients," and 38% responded that the information has affected their referrals to surgeons "very much" or "somewhat." CONCLUSIONS: A majority of cardiologists has not generally changed their well-established referral patterns as a result of the New York coronary artery bypass graft surgery reports. However, there has been a modest impact on referrals resulting from the distribution of these reports. The findings also suggest that increased dialogue between clinicians and policy makers regarding the format and structure of public releases would be a valuable undertaking.

Immunizations: the promise and the pitfalls.

Despite our success with eradicating smallpox and possibly poliomyelitis, the United States faces unacceptably low immunization levels among preschool-age children. The problems associated with ensuring complete protection of children from vaccine-preventable diseases are multifaceted. Many children remain at risk for potentially fatal diseases, and the easy transmissibility of these agents increases the threat of disease outbreaks. This commentary examines steps needed to improve immunization levels and pediatric primary care, access.