Ambulatory care sensitive hospitalizations and emergency visits: experiences of Medicaid patients using federally qualified health centers.

BACKGROUND: Federally Qualified Health Centers (FQHCs) serve as regular sources of preventive and primary care for low-income families within their communities and are key parts of the health care safety net. OBJECTIVES: Compare admissions and emergency room visits for ambulatory care sensitive conditions (ACSCs) among Medicaid beneficiaries relying on FQHCs to other Medicaid beneficiaries. RESEARCH DESIGN: Retrospective analysis of 1992 Medicaid claims data for 48,738 Medicaid beneficiaries in 24 service areas across five states. SUBJECTS: Medicaid beneficiaries receiving more than 50% of their preventive and primary care services from FQHCs are compared with Medicaid beneficiaries receiving outpatient care from other providers in the same areas. Exclusions-managed care enrollees, beneficiaries more than age 65, dual eligibles (Medicaid and Medicare), and institutionalized populations. MEASURES: Admissions and emergency room (ER) visits for a set of chronic and acute conditions, known in the literature as ambulatory care sensitive conditions (ACSCs). RESULTS: Medicaid beneficiaries receiving outpatient care from FQHCs were less likely to be hospitalized (1.5% vs. 1.9%, P < 0.007) or seek ER care (14.9% vs. 15.7%, P < 0.02) for ACSCs than the comparison group. Controlling for case mix and other demographic variables, the odds ratios were, for hospitalizations, OR, 0.80; 95% CI, 0.67 to 0.95; P < 0.01, and for ER visits, OR, 0.87; 95% CI, 0.82 to 0.92; P < 0.001. CONCLUSIONS: Having a regular source of care such as FQHCs can significantly reduce the likelihood of hospitalizations and ER visits for ACSCs. If the reported differentials in ACSC admissions and ER visits were consistently achieved for all Medicaid beneficiaries, substantial savings might be realized.

Mexican American infant mortality rate: implications for public policy.

Infants of Mexican American descent have lower infant mortality rates (IMRs) than do non-Hispanic blacks and non-Hispanic whites. Because IMR is used in allocation methods for primary health care resources, the result could be discrimination against Mexican American populations in the distribution of resources. This study examined the National Center for Health Statistics' infant birth and death records, as well as unpublished data from the Bureau of Primary Health Care. This study found that the low Mexican American IMRs are real and not simply a data anomaly and that inclusion of birth outcomes has a small and mixed effect on the designation of high-Hispanic areas as being medically underserved or short of primary health care professionals. The authors suggest inclusion of an additional high-Hispanic health indicator in the designation criteria for health resources.

The de novo design and synthesis of cyclic urea inhibitors of factor Xa: optimization of the S4 ligand.

In this report refinements to the S4 ligand group leads to compound 19, an inhibitor of fXa with good potency in vitro and an improved pharmacokinetic profile in rabbit. The X-ray crystallographic study of a representative analogue confirms our binding model for this series.

Targeting the underserved for breast and cervical cancer screening: the utility of ecological analysis using the National Health Interview Survey.

OBJECTIVES: This study tested the utility of ecological variables created from the National Health Interview Survey (NHIS) for strategic targeting of health services for the underserved. METHODS: Ecological variables were created using the 1989-1991 survey years of the NHIS public use data files. Segments, the NHIS secondary sampling units, permit computation of secondary sampling characteristics by percentage Black, percentage Hispanic, percentage below poverty, percentage unemployed, median education, median income, median age, and percentage residing in the United States for 5 years or less. These variables were analyzed with the NHIS Health Promotion and Disease Prevention 1990 supplement reporting mammogram, clinical breast examination, and Pap test use. RESULTS: Median education of areas was inversely related to never having mammograms. Areas with a high proportion (70%-100%) of Hispanic respondents also were more likely not to have mammograms. Women residing in areas with moderate or high proportions of Hispanic respondents were more likely never to have clinical breast examinations and Pap tests, as were those in areas with low income, poverty, and respondents who had resided in the United States 5 years or less. CONCLUSIONS: The new methodology of constructing ecological variables using the NHIS demonstrates an application that may help identify underserved areas or areas with underutilized services. More studies using this methodology are warranted.

Biochemical and crystallographic characterization of homologous non-peptidic thrombin inhibitors having alternate binding modes.

The X-ray crystallographic structure of [N-(3-phenylpropionyl)-N-(phenethyl)]-Gly-boroLys-OH (HPBK, Ki = 0. 42 nM, crystallographic R factor to 1.8 A resolution, 19.6%) complexed with human alpha-thrombin shows that the boron adopts a tetrahedral geometry and is covalently bonded to the active serine, Ser195. The HPBK phenethyl aromatic ring forms an edge-to-face interaction with the indole side chain of Trp215. Four HPBK analogs containing either electron-withdrawing or electron-donating substitutents at the 3' position of the phenethyl ring were synthesized in an attempt to modulate ligand affinity by inductive stabilization of the edge-to-face interaction. Refined crystallographic structures of the trifluoromethyl (Ki = 0.37 nM, crystallographic R factor to 2.0 A resolution = 18.7%), fluoro (Ki = 0.60; R factor to 2.3 A resolution = 18.4%), methoxy (Ki = 0.91 nM, R factor to 2.2 A resolution = 19.8%) and methyl (Ki = 0.20 nM, R factor to 2.5 A resolution = 16.9%) HPBK analogs complexed with thrombin revealed two binding modes for the closely related compounds. A less than 1.5-fold variation in affinity was observed for analogs (trifluoromethyl-HPBK and fluoro-HPBK) binding with the edge-to-face interaction. The slight inductive modulation is consistent with the overall weak nature of the edge-to-face interaction. Owing to an unexpected rotation of the phenethyl aromatic ring, the 3' substituent of two analogs, methoxy-HPBK and methyl-HPBK, made direct contact with the Trp215 indole side chain. Increased affinity of the 3' methyl analog is attributed to favorable interactions between the methyl group and the Trp215 indole ring. Differences in inhibitor, thrombin and solvent structure are discussed in detail. These results demonstrate the subtle interplay of weak forces that determine the equilibrium binding orientation of inhibitor, solvent and protein.

Who participates in cardiovascular disease risk factor screenings? Experience with a religious organization-based program.

Adult members who declined participation in cardiovascular disease risk factor screenings offered at religious organizations were randomly selected and asked to participate in screenings at their homes. Relationships between screening participation and sociodemographic, behavioral, and physiological measures were examined. Age, knowledge of cardiovascular disease risk factors, body mass index, current smoking status, previous report of elevated blood pressure, current diastolic blood pressure measurement, frequency of worship service attendance, and residential distance from the religious organization screening site were important predictors of screening response. Those with conspicuous risk factors appeared less likely to initially respond to religious organization site screening invitations.

Breast cancer screening among older racial/ethnic minorities and whites: barriers to early detection.

Screening mammography for early detection of breast cancer has been shown to be an effective method for reducing mortality in older women. Based on the results from the 1987-88 National Health Interview Survey, older minority women have low prevalence rates of screening mammography. Among women aged 75 and older, 83.5% of Black women, 93.2% of Hispanic women, and 75.0% of White women have never had a mammogram. On the average, about 12% of minority women over the age of 65 have had a screening mammogram within the preceding year, compared with about 15% of White women. Among women 75 + years of age, Black and Hispanic women had markedly lower rates of clinical breast examination in the last year (23.4% and 20.5% respectively) as compared to White women (35.2%). The most common reason for not having a mammogram among Black women 65 years of age and older was that the doctor did not recommend a mammogram. For Hispanic and White women in this age group, the most common reason was that a mammogram was not needed or not necessary. Aggressive and creative breast cancer screening activities for minority aged 65 and older are clearly indicated.

Stage at diagnosis in breast cancer: race and socioeconomic factors.

Cancer incidence data from three US metropolitan areas were coupled with census tract indicators of education and income. The data suggest that both Black and White cancer patients living in census tracts with lower median education/income values are diagnosed in later disease stages than are patients in tracts with higher median education/income values. Within education and income strata, Black women had a less favorable stage of disease at diagnosis than Whites. The exception was in upper education/income levels, where the disadvantage for Blacks disappeared. These data provide additional evidence that women of low socioeconomic status could benefit from targeted screening.

Correlates of expected success at health habit change and its role as a predictor in health behavior research.

Perceived ability to change health habits successfully is undoubtedly an important factor underlying personal health behavior. This report examines expected success in changing future habits, using a sample of community-resident adults 18-65 years of age (n = 1,367). One set of analyses used expected success as a dependent variable, whereas another set used it as an independent variable for health behavior and knowledge indices. In the dependent variable analysis, results showed that reported past success at health habit change was the strongest predictor of success expected in the future. Optimism about future success was also associated with variables that already placed individuals at an advantage to change behavior (e.g., not smoking, regular exercise, lower Body Mass Index, support in the family). When used as a predictor variable, expected future success was not associated with five health-related, self-report indices of behavior, knowledge, and perceived risk. Further examination showed, however, that in three instances the association between expected success and the outcome indices seemed to plateau in the most optimistic group. Extreme optimism (that admits no chance of failure) may be a belief characteristic that deserves further investigation, one that will present a challenge to research and practice. Men tended to report greater expected future success than women, although women had more favorable reports on three of the five health-related behavior/knowledge indices.

Characteristics of volunteers who deliver health education and promotion: a comparison with organization members and program participants.

The use of volunteers in this culture for community health endeavors is an understudied area. Yet, there may be many potential benefits for utilizing volunteers in the delivery of community health education and promotion. Volunteers may have more immediate access to their peers, credibility, and familiarity with the cultural environment and organization elements. An assumption of volunteer use is that persons drawn from a targeted organization (or community subgroup) will be like other members. Such an assumption, however, should be confirmed or disproved. This article compares a sample of volunteers to a sample of members from organizations from which the volunteers were recruited. The paper also compares the volunteers to a sample of program participants. The participants were persons to whom the volunteers delivered CVD prevention programming and, in most cases, were also organization members. Collectively using the variables under investigation, multivariate analyses of variance found that the volunteers were different from the organization members, and different from program participants. To assess differences between the samples on each individual variable, univariate tests were conducted stratifying the samples by age. Statistically significant differences were found regarding organization activity, formal education level, success with past health habit change, health self-assessment, occupation, gender, and marital status.

Volunteers as providers of heart health programs in churches: a report on implementation.

Abstract This project studies the use of church volunteers to reduce cardiovascular disease risk factors among their fellow church members. Our findings focus on the first 12 months of the project and address the following questions: 1) Can volunteers implement these programs with no on-site professional staff? 2) Are volunteer efforts facilitated by a local volunteer task force? and 3) Are implementation efforts aided by readily available professional staff involvement? In the intervention churches, 220 certified Risk Factor Leaders conducted 82 group programs with 740 registrants and 104 blood pressure screenings with 1,834 contacts. Our study shows volunteers to be effective implementers of heart health programs in churches. The involvement of a task force seemed to facilitate volunteer recruitment. Churches with a lower level of professional involvement had more blood pressure screenings. The effect of a task force or professional assistance on other volunteer efforts did not reach statistical significance.

Training volunteers to conduct heart health programs in churches.

With cardiovascular disease the leading cause of death and disability in the United States, economically feasible and effective methods of prevention are needed. The Health and Religion Project (HARP) uses volunteers to provide cardiovascular risk-factor change programs to individuals in their church communities. The rationale for the use of volunteers in this setting is described, along with the design and initial response to the HARP volunteer training program. Two hundred twenty-two volunteers were certified across 16 study churches to conduct risk-factor change programs. Their certification exam performance demonstrated that they had mastered the knowledge and skills deemed necessary for their jobs. Overall, the trainees were very enthusiastic about their new roles. Based on this initial response, our partnership with churches for health promotion is worthy of further development.

The role of churches in disease prevention research studies.

The design of a large-scale research project (The Health and Religion Project) in which church volunteers deliver behavior change programming on major cardiovascular risk factors (smoking, elevated blood pressure, elevated serum cholesterol, excess weight, and physical inactivity) is described. A total of 20 churches (Roman Catholic, Baptist, and Episcopal) were recruited throughout Rhode Island and randomly assigned to five experimental conditions. These conditions were designed to test the necessity of training special task forces to coordinate efforts within each church and to test the relative efficacy of high or low levels of professional (paid staff) involvement. Churches have many characteristics that are compatible with behavior change programming for primary prevention of chronic diseases. However, there have been very few research studies of churches engaging in primary prevention activities. Thus, the first step was to test the churches' receptivity to participation in this type of project. To do this, all churches in Rhode Island were surveyed by mail and phone. Those that met several eligibility criteria were randomly selected for recruitment into the study. The high receptivity of the churches was demonstrated by a response rate of 65 percent (20 of 31). This readiness is bolstered by the fact that all of the 20 churches that originally began the study have remained involved for at least 2 1/2 years.

Applications of behavior modification to community health education: the case of heart disease prevention.

Principles of behavior modification increasingly have been applied to community health education and offer considerable promise for public health in general. Behavior modification procedures can be conceptualized in a 2 X 2 framework with desired goals being either to increase and strengthen or decrease and weaken behavior, and procedures producing essentially positive or negative consequences. Modifying specific behavioral risk factors for the prevention of heart disease may include the use of positive reinforcement, shaping, differential reinforcement, negative reinforcement, and "punishment." The use of an adequate "behavior analytic" history, highly acceptable interventions, observable effects, inexpensive materials and procedures, community-owned programs, and other practical guidelines can help optimize the effectiveness of behavior modification for health education in the community.