Drospirenone and non-fatal venous thromboembolism: is there a risk difference by dosage of ethinyl-estradiol?

BACKGROUND: Previous studies concluded that there was an increased risk of non-fatal venous thromboembolism (VTE) with drospirenone. It is unknown whether the risk is differential by ethinyl-estradiol dosage. OBJECTIVES: To assess the risk of VTE with drospirenone and to determine whether drospirenone and ethinyl-estradiol 20 µg (DRSP/EE20) has a lower VTE risk than drospirenone and ethinyl-estradiol 30 µg (DRSP/EE30). METHODS: Our cohort included women aged 18-46 years taking drospirenone or levonorgestrel (LNG)-containing combined oral contraceptives (COCs) in the IMS claims database between 2001 and 2009. VTE was defined using ICD-9-CM coding and anticoagulation. The hazard ratio (HR) from Cox proportional hazards models was used to assess the VTE relative risk (RR) with drospirenone compared with levonorgestrel, adjusted by a propensity score used to control for baseline co-morbidity and stratified by EE dosage and user-type (new/current). RESULTS: The study included 238 683 drospirenone and 193,495 levonorgestrel users. Among new and current users, a 1.90-fold (95% CI, 1.51-2.39) increased VTE relative risk was observed for drospirenone (18.0 VTE/10,000 women-years) vs. levonorgestrel (8.9 VTE/10,000 women-years). In analysis of new users, DRSP/EE20 had a 2.35-fold (95% CI, 1.44-3.82) VTE RR versus LNG/EE20. New users of DRSP/EE30 observed an increased RR versus LNG/EE30 among women starting to use COCs between 2001 and 2006 (2.51, 95% CI, 1.12-5.64) but not between 2007 and 2009 (0.76, 95% CI, 0.42-1.39), attributable to an increased incidence rate with LNG/EE30 from 2007 to 2009. In direct comparison, DRSP/EE20 had an elevated risk of VTE compared with DRSP/EE30 (RR, 1.55; 95% CI, 0.99-2.41). CONCLUSIONS: We observed a modestly elevated risk of VTE with drospirenone, compared with levonorgestrel. The larger VTE incidence rate observed in DRSP/EE20 than in DRSP/EE30 and the increasing VTE incidence rate with levonorgestrel between 2007 and 2009 were unexpected.

Perceived race-based and socioeconomic status(SES)-based discrimination in interactions with health care providers.

OBJECTIVE: The purpose of this study was to: 1) examine whether African Americans perceive race-based and socioeconomic status(SES)-based discrimination in their interactions with health care providers; 2) explore the relationship between perceived discrimination and health care utilization; and 3) examine the interrelationships among education, stigma consciousness, and perceived discrimination. DESIGN: Cross-sectional. METHODS: Seventy-six African-American adults (59 women and 17 men) completed self-report questionnaires regarding their experiences with and attitudes toward health care providers. RESULTS: Almost two thirds (63%) of participants perceived discrimination in their interactions with health care providers based on their race or color, and 58.9% perceived discrimination based on their socioeconomic status or social class. Some experiences of perceived discrimination were correlated with measures of health care utilization. Education and stigma consciousness were positively correlated with perceptions of both race-based and SES-based discrimination. Stigma consciousness was not significantly correlated with education, suggesting that expectations that one will be stereotyped by doctors do not account for the relationship between education and reports of perceived discrimination in interactions with health care providers. CONCLUSION: Further research is needed to assess the prevalence, frequency, and consequences of perceived discrimination in health care interactions.

Comparing the acceptability of manual vacuum aspiration and electric vacuum aspiration as methods of early abortion.

OBJECTIVE: to compare the acceptability of manual vacuum aspiration (MVA) and electric vacuum aspiration (EVA) as methods of early (< or = 77 days' gestation) abortion. METHODS: We interviewed 42 women who had been randomly assigned to either MVA or EVA and compared their perceptions of the two procedures. RESULTS: The experiences and perceptions of women in the two groups were similar in many ways. The majority of women in both procedure groups were very satisfied with the method used, and most indicated that they would prefer the same method if they were to have another abortion. CONCLUSION: This study found no major differences in the acceptability of MVA and EVA among women undergoing early abortions.

Beyond marital status: relationship type and duration and the risk of low birth weight.

CONTEXT: Unmarried women have higher rates of low birth weight than married women. However, assumptions that unmarried women are uniformly at a disadvantage may be unfounded. A woman's relationship characteristics may be more relevant for infant health than her formal marital status. METHODOLOGY: Data from the 1995 National Survey of Family Growth were used to analyze associations between relationship characteristics and low birth weight among U.S. women aged 15-44 with a recent singleton live birth. Unadjusted odds ratios were generated to indicate the crude effects of independent variables, including relationship type and relationship duration at the time of conception. Multiple logistic regressions were performed to assess the impact of relationship variables on the likelihood of low birth weight, taking into account the effects of other covariates. RESULTS: In multivariate models of all women and non-Hispanic black women, relationship type and duration were not associated with low birth weight. However, low birth weight was almost six times as likely among Hispanic women in nonmarital, noncohabiting relationships as among those who were married. Surprisingly, among non-Hispanic white women, low birth weight was less likely among those in nonmarital, noncohabiting relationships than among those who were married. Unexpected associations also were found among low birth weight, race and ethnicity, and relationship duration: Low birth weight was more likely among non-Hispanic white women in relationships of from five to 10 years in length than among those in relationships of longer than 10 years and less likely among Hispanic women in relationships of one year or less than among those in a relationship for more than 10 years. CONCLUSION: Although unmarried women in the United States have higher rates of low birth weight than married women, many unmarried women are at no greater risk of low birth weight than their married counterparts. The findings confirm the need to consider the characteristics of relationships when examining the association of mother's "union status" and birth outcomes.

State-level infant, neonatal, and postneonatal mortality: the contribution of selected structural socioeconomic variables.

Reducing infant mortality in the United States is a national priority. States' infant mortality rates vary substantially. Public health researchers, practitioners, and leaders have long argued that social and other structural factors must be addressed if health outcomes are to be improved. A knowledge of which structural variables are most strongly related to state-level infant mortality is needed to guide the development of policies and programs to reduce this mortality. The authors examine the importance of several structural (social, economic, and political) variables for state-level infant, neonatal, and postneonatal mortality. With the state as the unit of analysis, data for all 50 states were analyzed using multiple regression. Together, the structural variables accounted for two-thirds of the variance in infant and neonatal mortality rates and over half of the variance in postneonatal mortality rates. States with proportionately larger black populations had higher infant, neonatal, and postneonatal mortality rates. States with greater percentages of high school graduates had lower neonatal mortality rates but higher postneonatal mortality rates. The findings suggest that a better understanding of the relationship between states' social structure and infant health outcomes is needed if state-level infant mortality is to be reduced.

Disease ecology and a reformist alternative: the case of infant mortality.

This paper attempts to shed some light on the recent debate between those who advocate a reformed medical geography and those who respond that reform is not necessary. We show that disease ecology and a reformist alternative display certain tendencies in the ways in which they address issues of health and disease. We use the example of geographic variations in infant mortality rates to show how two non-positivist perspectives from social theory, political economy and humanism, support a reformist viewpoint, while also acknowledging the value of a complementary disease ecology approach. Two concepts, the social construction of health and illness and social relevance, are used to portray the political economy approach; humanism is described in terms of the meaning of individual experience and the importance of place. The paper concludes with a discussion of the respective roles of disease ecology and a reformist approach in models of infant mortality and a summary of the main differences between the two perspectives.

Separate black and white infant mortality models: differences in the importance of structural variables.

In the United States, the disparity in black and white infant mortality persists despite reductions in overall infant mortality. In 1988, 23 of the 50 states had a black infant mortality rate that was more than twice as large as its white infant mortality rate. This study assesses whether state-level structural variables relate differentially to states' black and white infant mortality rates. With the state as the unit of analysis, separate black (N = 34) and white (N = 50) multivariate models of infant mortality were produced and compared. The structural variables accounted for 57.7% of the variance in states' black infant mortality rates and 35.2% of the variance in states' white infant mortality rates. Proportion black, percent with bachelor's degree or higher, percent below poverty, and the index of dissimilarity each made a unique contribution to the black infant mortality model. Percent with bachelor's degree or higher was the only measure that made a significant unique contribution to the white infant mortality model. Thus, although both black and white infant mortality rates were higher in states with smaller percentages of the population having a bachelor's degree or higher, black infant mortality rates were also higher in states where proportionately more black persons lived, where there were higher levels of residential segregation in the urban areas, and, contrary to what was expected, where smaller percentages of the population lived below the poverty level. This study supports the need for race-specific models of infant mortality.

The relationship between structural and health services variables and state-level infant mortality in the United States.

OBJECTIVES: This study compared the relative strength of the associations of a set of structural (social, economic, and political) variables and a set of health services variables with state-level infant, neonatal, and postneonatal mortality. It also examined whether health services mediate the relationships between structural variables and state-level infant, neonatal, and postneonatal mortality. METHODS: With the state as the unit of analysis, data for all 50 states were analyzed by means of multiple regression. RESULTS: Structural variables accounted for substantially more variance in infant, neonatal, and postneonatal mortality than health services variables, and health services variables were more strongly related to infant mortality than to neonatal or postneonatal mortality. When health services variables were controlled, the strengths of the associations between the structural variables and infant, neonatal, and postneonatal mortality were reduced but remained statistically significant. CONCLUSIONS: A substantial portion of the variance in state-level infant mortality is accounted for by states' structural characteristics, which are partially mediated by health services.

Patient education for sickle cell disease: a national survey of health care professionals.

Despite emphasis on including patient and parent education in sickle cell comprehensive clinical care, literature on the use of such materials is scarce. To discover the availability of, satisfaction with, use of and interest in patient and parent education materials for sickle cell disease, we surveyed, with a 176-item self-administered questionnaire, 209 sickle cell professionals nationwide. Respondents came from 74 sickle cell programs, were 63.4% female and 37.7% African American, and represented many health professions. We found that materials about patient behavior and psycho-social issues, as opposed to those about the disease and treatment, were more often unavailable and, when available, more often unsatisfactory and less frequently used. When available, use of materials was unrelated to satisfaction and perceptions of patient problems for most topics. For each of 10 topics, over 90% of the respondents were interested in materials covering the topic. Future research should examine the low to moderate use of psycho-social and behavioral materials with sickle cell patients, and should assess the appropriateness and effectiveness of existing and new materials.

Toward integrating qualitative and quantitative methods: an introduction.

Both the qualitative and quantitative paradigms have weaknesses which, to a certain extent, are compensated for by the strengths of the other. As indicated in this article, the strengths of quantitative methods are that they produce factual, reliable outcome data that are usually generalizable to some larger population. The strengths of qualitative methods are that they generate rich, detailed, valid process data that usually leave the study participants' perspectives in tact. This article discusses how qualitative and quantitative methods can be combined and it introduces the articles included in this issue.