Variation in inpatient tonsillectomy costs within and between US hospitals attributable to postoperative complications.

BACKGROUND: Tonsillectomy is the second most common inpatient procedure in US children. However, the factors that influence tonsillectomy-related costs are unknown. OBJECTIVE: The objective of the study was to describe variation in US inpatient tonsillectomy costs and examine whether postoperative complications contribute to these disparities in costs. RESEARCH DESIGN: This is a retrospective cohort study of the 2009 Nationwide Inpatient Sample. Hierarchical, mixed-effects linear regression modeling was used to analyze the association between postoperative complications and cost, controlling for clinically relevant characteristics such as age, number of chronic comorbidity indicators, and hospital mean complication rates. We also estimated the variance in cost attributable to the treating hospital using the intraclass correlation coefficient. SUBJECTS: The study cohort comprised 12,512 adult and pediatric patients undergoing tonsillectomy or adenotonsillectomy in the inpatient setting. MEASURES: Cost, posttonsillectomy hemorrhage, and mechanical ventilator use at the individual encounter and at hospital level were evaluated. RESULTS: The aggregate cost of tonsillectomies in the cohort was $94.2 million. The median cost per encounter across all hospitals was $4393 (interquartile range, $3279-$6981), whereas the mean cost was $7525 (95% confidence interval, $6453-$8597). Mechanical ventilation was associated with an adjusted increase of $30,081 per encounter (95% confidence interval, $18,199-$41,964). The intraclass correlation coefficient declined from 0.117 to 0.070 after adjusting for mean hospital mechanical ventilation rate, which accounted for 40.2% of the interhospital variation in cost. CONCLUSIONS: Use of mechanical ventilation significantly increases the cost of inpatient tonsillectomy care. Further research should examine risk factors contributing to higher rates of mechanical ventilation after tonsillectomy, which in turn can guide systemic quality improvement interventions to reduce costs.

The voices of limited English proficiency Latina mothers on pediatric primary care: lessons for the medical home.

The objective of this study is to inform medical home implementation in practices serving limited English proficiency Latino families by exploring limited English proficiency Latina mothers' experiences with, and expectations for, pediatric primary care. In partnership with a federally-qualified community health center in an urban Latino neighborhood, we conducted semi-structured interviews with 38 low-income Latina mothers. Eligible participants identified a pediatric primary care provider for their child and had at least one child 3 years old or younger, to increase the probability of frequent recent interactions with health care providers. Interview transcripts were coded and analyzed through an iterative and collaborative process to identify participants' satisfaction with and expectations for pediatric primary care. About half of the mothers interviewed were satisfied with their primary care experiences. Mothers suggested many ways to improve the quality of pediatric primary care for their children to better meet the needs of their families. These included: encouraging providers to invest more in their relationship with families, providing reliable same-day sick care, expanding hours, improving access to language services, and improving care coordination services. Limited English proficiency Latina mothers expect high-quality pediatric primary care consistent with the medical home model. Current efforts to improve primary care quality through application of the medical home model are thus relevant to this population, but should focus on the parent-provider relationship and timely access to care. Promoting this model among practices that serve limited English proficiency Latino families could improve engagement and satisfaction with primary care.

American Muslim perceptions of healing: key agents in healing, and their roles.

American Muslims represent a growing and diverse community. Efforts at promoting cultural competence, enhancing cross-cultural communication skills, and improving community health must account for the religio-cultural frame through which American Muslims view healing. Using a community-based participatory research model, we conducted 13 focus groups at area mosques in southeast Michigan to explore American Muslim views on healing and to identify the primary agents, and their roles, within the healing process. Participants shared a God-centric view of healing. Healing was accessed through direct means such as supplication and recitation of the Qur'an, or indirectly through human agents including imams, health care practitioners, family, friends, and community. Human agents served integral roles, influencing spiritual, psychological, and physical health. Additional research into how religiosity, health care systems, and community factors influence health-care-seeking behaviors is warranted.

The role of imams in American Muslim health: perspectives of Muslim community leaders in Southeast Michigan.

American Muslims are a diverse and growing population, numbering nearly 200,000 in Southeast Michigan. Little empirical work exists on the influence of Islam upon the healthcare behaviors of American Muslims, and there is to date limited research on the roles that imams, Muslim religious leaders, play in the health of this community. Utilizing a community-based participatory research (CBPR) model through collaboration with four key community organizations, we conducted semi-structured interviews with 12 community leaders and explored their perceptions about the roles imams play in community health. Respondents identified four central roles for imams in healthcare: (1) encouraging healthy behaviors through scripture-based messages in sermons; (2) performing religious rituals around life events and illnesses; (3) advocating for Muslim patients and delivering cultural sensitivity training in hospitals; and (4) assisting in healthcare decisions for Muslims. Our analysis also suggests several challenges for imams stemming from medical uncertainty and ethical conflicts. Imams play key roles in framing concepts of health and disease and encouraging healthy lifestyles outside of the healthcare system, as well as advocating for Muslim patient needs and aiding in healthcare decisions within the hospital. Healthcare partnerships with these religious leaders and their institutions may be an important means to enhance the health of American Muslims.

Comfort of general internists and general pediatricians in providing care for young adults with chronic illnesses of childhood.

BACKGROUND: As an increasing number of patients with chronic conditions of childhood survive to adulthood, experts recommend that young adults with chronic conditions transfer from child-focused to adult-focused primary care. Little, however, is known about how comfortable physicians are caring for this population. OBJECTIVES: To assess the comfort of general internists and general pediatricians in treating young adult patients with chronic illnesses originating in childhood as well as the factors associated with comfort. PARTICIPANTS: In a random sample, 1288 of 2434 eligible US general internists and pediatricians completed a mailed survey (response rate = 53%). METHODS: We measured respondents' comfort level in providing primary care for a patient with sickle cell disease (SCD) or cystic fibrosis (CF). We also measured levels of disease familiarity, training and subspecialty support, as well as individual physician characteristics. RESULTS: Fifteen percent of general internists reported being comfortable as the primary care provider for adults with CF and 32% reported being comfortable providing primary care for adults with SCD, compared with 38% of pediatricians for CF (p < .001) and 35% for SCD (p > 0.05). Less than half of general internists felt that their specialty should take primary care responsibility for adult patients with CF and SCD. CONCLUSIONS: A majority of general internists and pediatricians are not comfortable providing primary care for young adults with chronic illnesses of childhood origin, such as CF and SCD. Efforts to increase treatment comfort among providers may help with the transition to adult-focused care for the growing numbers of young adults with complex chronic conditions.

Payer leverage and hospital compliance with a benchmark: a population-based observational study.

BACKGROUND: Since 1976, Medicare has linked reimbursement for hospitals performing organ transplants to the attainment of certain benchmarks, including transplant volume. While Medicare is a stakeholder in all transplant services, its role in renal transplantation is likely greater, given its coverage of end-stage renal disease. Thus, Medicare's transplant experience allows us to examine the role of payer leverage in motivating hospital benchmark compliance. METHODS: Nationally representative discharge data for kidney (n = 29,272), liver (n = 7,988), heart (n = 3,530), and lung (n = 1,880) transplants from the Nationwide Inpatient Sample (1993-2003) were employed. Logistic regression techniques with robust variance estimators were used to examine the relationship between hospital volume compliance and Medicare market share; generalized estimating equations were used to explore the association between patient-level operative mortality and hospital volume compliance. RESULTS: Medicare's transplant market share varied by organ [57%, 28%, 27%, and 18% for kidney, lung, heart, and liver transplants, respectively (P < 0.001)]. Volume-based benchmark compliance varied by transplant type [85%, 75%, 44%, and 39% for kidney, liver, heart, and lung transplants, respectively (P < 0.001)], despite a lower odds of operative mortality at compliant hospitals. Adjusting for organ supply, high market leverage was independently associated with compliance at hospitals transplanting kidneys (OR, 143.00; 95% CI, 18.53-1103.49), hearts (OR, 2.84; 95% CI, 1.51-5.34), and lungs (OR, 3.24; 95% CI, 1.57-6.67). CONCLUSION: These data highlight the influence of payer leverage-an important contextual factor in value-based purchasing initiatives. For uncommon diagnoses, these data suggest that at least 30% of a provider's patients might need to be "at risk" for an incentive to motivate compliance.

Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns.

BACKGROUND: The Botswana government recently implemented a policy of routine or "opt-out" HIV testing in response to the high prevalence of HIV infection, estimated at 37% of adults. METHODS AND FINDINGS: We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana to assess knowledge of and attitudes toward routine testing, correlates of HIV testing, and barriers and facilitators to testing, 11 months after the introduction of this policy. Most participants (81%) reported being extremely or very much in favor of routine testing. The majority believed that this policy would decrease barriers to testing (89%), HIV-related stigma (60%), and violence toward women (55%), and would increase access to antiretroviral treatment (93%). At the same time, 43% of participants believed that routine testing would lead people to avoid going to the doctor for fear of testing, and 14% believed that this policy could increase gender-based violence related to testing. The prevalence of self-reported HIV testing was 48%. Adjusted correlates of testing included female gender (AOR = 1.5, 95% CI = 1.1-1.9), higher education (AOR = 2.0, 95% CI = 1.5-2.7), more frequent healthcare visits (AOR = 1.9, 95% CI = 1.3-2.7), perceived access to HIV testing (AOR = 1.6, 95% CI = 1.1-2.5), and inconsistent condom use (AOR = 1.6, 95% CI = 1.2-2.1). Individuals with stigmatizing attitudes toward people living with HIV and AIDS were less likely to have been tested for HIV/AIDS (AOR = 0.7, 95% CI = 0.5-0.9) or to have heard of routine testing (AOR = 0.59, 95% CI = 0.45-0.76). While experiences with voluntary and routine testing overall were positive, 68% felt that they could not refuse the HIV test. Key barriers to testing included fear of learning one's status (49%), lack of perceived HIV risk (43%), and fear of having to change sexual practices with a positive HIV test (33%). CONCLUSIONS: Routine testing appears to be widely supported and may reduce barriers to testing in Botswana. As routine testing is adopted elsewhere, measures should be implemented to assure true informed consent and human rights safeguards, including protection from HIV-related discrimination and protection of women against partner violence related to testing.

A population-based study on alcohol and high-risk sexual behaviors in Botswana.

BACKGROUND: In Botswana, an estimated 24% of adults ages 15-49 years are infected with HIV. While alcohol use is strongly associated with HIV infection in Africa, few population-based studies have characterized the association of alcohol use with specific high-risk sexual behaviors. METHODS AND FINDINGS: We conducted a cross-sectional, population-based study of 1,268 adults from five districts in Botswana using a stratified two-stage probability sample design. Multivariate logistic regression was used to assess correlates of heavy alcohol consumption (>14 drinks/week for women, and >21 drinks/week for men) as a dependent variable. We also assessed gender-specific associations between alcohol use as a primary independent variable (categorized as none, moderate, problem and heavy drinking) and several risky sex outcomes including: (a) having unprotected sex with a nonmonogamous partner; (b) having multiple sexual partners; and (c) paying for or selling sex in exchange for money or other resources. Criteria for heavy drinking were met by 31% of men and 17% of women. Adjusted correlates of heavy alcohol use included male gender, intergenerational relationships (age gap > or =10 y), higher education, and living with a sexual partner. Among men, heavy alcohol use was associated with higher odds of all risky sex outcomes examined, including unprotected sex (AOR = 3.48; 95% confidence interval [CI], 1.65 to 7.32), multiple partners (AOR = 3.08; 95% CI, 1.95 to 4.87), and paying for sex (AOR = 3.65; 95% CI, 2.58 to 12.37). Similarly, among women, heavy alcohol consumption was associated with higher odds of unprotected sex (AOR = 3.28; 95% CI, 1.71 to 6.28), multiple partners (AOR = 3.05; 95% CI, 1.83 to 5.07), and selling sex (AOR = 8.50; 95% CI, 3.41 to 21.18). A dose-response relationship was seen between alcohol use and risky sexual behaviors, with moderate drinkers at lower risk than both problem and heavy drinkers. CONCLUSIONS: Alcohol use is associated with multiple risks for HIV transmission among both men and women. The findings of this study underscore the need to integrate alcohol abuse and HIV prevention efforts in Botswana and elsewhere.

Young maternal age associated with increased risk of postneonatal death.

OBJECTIVE: To determine whether full-term, healthy infants born to early adolescent mothers (15 years old and younger) are at higher risk of postneonatal death compared with infants of adult mothers. METHODS: We combined the comprehensive 1996 and 1997 United States birth cohorts to compare postneonatal mortality rates among maternal age groups. With postneonatal death as our main outcome measure, we used multivariable logistic regression to model adjusted odds ratios. RESULTS: The postneonatal mortality rate for infants born to mothers 15 years old and younger was substantially higher (3.2 per 1000) than that of infants born to mothers 23-29 years old (0.8 per 1000) and remained substantially higher after adjusting for maternal race or ethnicity. Even after adjusting for maternal race or ethnicity, prenatal care utilization, and marital status, infants born to early adolescent mothers had a three-fold higher risk (odds ratio 3.0, 95% confidence interval 2.5, 3.6) of postneonatal death compared with adult mothers. CONCLUSION: Healthy infants born to early adolescent mothers are at increased risk of postneonatal death. Many of these deaths are potentially preventable; therefore, developing targeted postnatal support services specifically designed to address the needs of healthy infants born to adolescent mothers might have a positive effect on the lives of these children.

The risk for infant mortality among adolescent childbearing groups.

OBJECTIVE: To evaluate risk disparities and risk factors for infant mortality among adolescent childbearing age groups. METHODS: We combined the 1995 and 1996 comprehensive U.S. birth cohorts provided by the National Center for Heath Statistics. Our analysis included 777,762 singleton, first births to women aged 12-19 years linked to 4631 infant deaths. We used both bivariate comparisons and multivariable logistic regression for our analysis, with infant mortality as our main outcome measure. RESULTS: Rates of infant mortality are substantially higher for < or =15-year-olds (8.1/1000 live births) compared with 16-17-year-olds (6.3/1000 live births) and 18-19-year-olds (5.4/1000 live births). Even after adjusting for risk factors associated with poor outcomes, including alcohol use, tobacco use, and prenatal care use, the risk for infant mortality was 1.6 (95% confidence interval [95% CI] 1.4, 1.7) times greater for infants of mothers < or =15 years old as compared with those mothers 18-19 years old. In the < or =15-year-old group, 62% of fathers were not reported on the child's birth certificate. Not reporting the father was associated with a 24% increased risk for infant mortality after adjusting for maternal and infant risk factors. CONCLUSIONS: Childbearing in < or =15-year-olds is associated with a substantial increased risk for infant mortality compared with childbearing in older adolescence. This study suggests that not reporting the father on a birth certificate is a potential risk marker. Risk differences among adolescent age groups may be important to consider when creating tailored intervention and prevention strategies.

Medicaid managed care: are academic medical centers penalized by attracting patients with high-cost conditions?

OBJECTIVE: To determine whether case-mix and health utilization disparities exist between Medicaid enrollees within a Michigan managed care organization (MCO) who selected primary care providers (PCPs) affiliated with a major academic medical center (AMC) and enrollees who selected community providers. STUDY DESIGN: A retrospective cohort study using cost estimates obtained from claims data and based on a standardized Medicaid fee schedule. METHODS: We established the prevalence of 25 high-cost chronic medical conditions from the claims data for capitated Medicaid enrollees from January 1, 1997, through October 31, 1999. We assessed differences in healthcare cost estimates per member for Medicaid enrollees at AMC primary care sites versus other community sites using t tests and linear regressions, including analyses stratified for Temporary Assistance for Needy Families (TANF) and Aid to Blind and Disabled (ABAD) programs. RESULTS: Enrollees with AMC providers had a much higher cumulative prevalence of the 25 high-cost chronic medical conditions (95.6 per 1000 enrollees versus 65.6 per 1000; P < .001), and virtually all of this difference was confined to ABAD enrollees. Estimated total costs were also higher for ABAD Medicaid enrollees at the AMC sites than for those at community sites. The average total services and pharmacy cost estimates per ABAD member were $1219 higher per member per year at the AMC sites (P < .001), primarily from costs of inpatient hospitalizations. Regression analyses demonstrated that differences in the prevalence of the 25 high-cost chronic medical conditions accounted for about 50% of the cost differences observed between sites. These analyses suggest that at least half of the observed cost disparity was due to adverse selection. CONCLUSIONS: This study found both significant case-mix and cost disparities for ABAD patients, suggesting that AMC primary care sites experienced substantial adverse selection. Unless approaches to account for adverse selection are put in place, this phenomenon could jeopardize ABAD Medicaid recipients' ongoing access to needed medical care.

Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996-2006.

BACKGROUND: Traditionally, thyroid surgery has been an inpatient procedure due to the risk of several well-documented complications. Recent research suggests that for selected patients, outpatient thyroid surgery is safe and feasible, with the additional potential benefit of cost savings. In recognition of these observations, we hypothesized that there would be an increase in U.S. outpatient thyroidectomies with a concurrent decline in inpatient thyroidectomies over time. METHODS: Comparative cross-sectional analyses of the National Survey of Ambulatory Surgery (NSAS) and Nationwide Inpatient Sample (NIS) databases from 1996 and 2006 were performed. All cases of thyroid surgery were extracted, as well as data on age, sex, and insurance status. Diagnoses and surgical cases were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic and treatment codes. Hospital charges were acquired from the NIS 1996 and 2006 and NSAS 2006 releases, using imputed data where necessary. After survey weights were applied, patient characteristics, diagnoses, and procedures were compared for inpatient versus outpatient procedures. RESULTS: The total number of thyroidectomies increased 39%, from 66,864 to 92,931 cases per year during the study timeframe. Outpatient procedures increased by 61%, while inpatient procedures increased by 30%. The proportion of privately insured inpatients declined slightly from 63.8% to 60.1%, while those covered by Medicare increased from 22.8% to 25.8%. In contrast, the proportion of privately insured outpatients declined sharply from 76.8% to 39.9%, while those covered by Medicare rose from 17.2% to 45.7%. These trends coincided with a small increase in the mean inpatient age from 50.2 to 52.3 years and a larger increase in the mean outpatient age from 50.7 to 58.1 years. Inflation-adjusted per-capita charges for inpatient thyroidectomies more than doubled from $9,934 in 1996 to $22,537 in 2006, while aggregate national inpatient charges tripled from $464 million to $1.37 billion. By comparison, per-capita charges for outpatient thyroidectomy totaled $7,222 in 2006. CONCLUSIONS: From 1996 to 2006, there has been a concurrent modest increase in inpatient and pronounced increase in outpatient thyroidectomies in the United States, with a consequential demographic shift and economic impact.

When coverage expands: children's health insurance program as a natural experiment in use of health care services.

BACKGROUND: Expanding insurance coverage is designed to improve access to primary care and reduce use of emergency department (ED) services. Whether expanding coverage achieves this is of paramount importance as the United States prepares for the Affordable Care Act. OBJECTIVES: Emergency and outpatient department use was examined after the State Children's Health Insurance Program (CHIP) coverage expansion, focusing on adolescents (a major target group for CHIP) versus young adults (not targeted). The hypothesis was that coverage would increase use of outpatient services, and ED use would decrease. METHODS: Using the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), the years 1992-1996 were analyzed as baseline and then compared to use patterns in 1999-2009, after the CHIP launch. Primary outcomes were population-adjusted annual visits to ED versus nonemergency outpatient settings. Interrupted time series were performed on use rates to ED and outpatient departments between adolescents (11 to 18 years old) and young adults (19 to 29 years old) in the pre-CHIP and CHIP periods. Outpatient-to-ED ratios were calculated and compared across time periods. A stratified analysis by payer and sex was also performed. RESULTS: The mean number of outpatient adolescent visits increased by 299 visits per 1,000 persons (95% confidence interval [CI] = 140 to 457), while there was no statistically significant increase in young adult outpatient visits across time periods. There was no statistically significant change in the mean number of adolescent ED visits across time periods, while young adult ED use increased by 48 visits per 1,000 persons (95% CI = 24 to 73). The adolescent outpatient-to-ED ratio increased by 1.0 (95% CI = 0.49 to 1.6), while the young adults ratio decreased by 0.53 across time periods (95% CI = -0.90 to -0.16). CONCLUSIONS: Since CHIP, adolescent non-ED outpatient visits have increased, while ED visits have remained unchanged. In comparison to young adults, expanding insurance coverage to adolescents improved use of health care services and suggests a shift to non-ED settings. Expanding insurance through the Affordable Care Act of 2010 will likely increase use of outpatient services, but may not decrease ED volumes.

The influence of evidence in the surgical treatment of thumb basilar joint arthritis.

BACKGROUND: For surgical treatment of thumb carpometacarpal joint arthritis, current evidence suggests that simple trapeziectomy is as effective as and may be safer than trapeziectomy and ligament reconstruction with or without tendon interposition. The authors examined whether current practice patterns in the surgical treatment of thumb carpometacarpal joint arthritis reflect adoption of simple trapeziectomy as best practice, and investigated whether surgeon preferences and third-party payer patterns are associated with use of simple trapeziectomy. METHODS: The authors performed a retrospective cross-sectional study of 6776 surgical treatments for thumb carpometacarpal joint arthritis using the all-payer State Ambulatory Surgery Database for Florida, from 2006 to 2009. Multinomial regression analysis was applied to examine associations between covariates, describing surgeon and third-party payer factors and type of procedure performed. An intraclass correlation coefficient was calculated to determine how much of the difference in patient outcome (procedure type) is attributable to differences between surgeons. RESULTS: Across surgeon characteristics included in the analysis, patients' outcome probabilities were over 90 percent in favor of treatment with trapeziectomy and ligament reconstruction with or without tendon interposition. The level of intraclass correlation among patients clustered within a surgeon showed that individual surgeons contribute substantially to determining what procedure type a patient undergoes. CONCLUSIONS: In this multiyear, one-state study, current evidence demonstrating the equivalent effectiveness of simple trapeziectomy compared with more involved alternatives did not result in wide adoption of the technique. This finding is consistent with studies in many clinical disciplines that highlight the difficulty of influencing clinical practice with available evidence.

Posttonsillectomy hemorrhage in children with von Willebrand disease or hemophilia.

IMPORTANCE: It is uncertain whether children with bleeding disorders are at higher risk of posttonsillectomy hemorrhage compared with the general pediatric population. OBJECTIVES: To estimate the national rate of posttonsillectomy hemorrhage in children previously diagnosed with von Willebrand disease (VWD) or hemophilia, and to analyze potential risk factors for postoperative bleeding in these children. DESIGN: A cross-sectional analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) from the Agency for Healthcare Research and Quality for 2000, 2003, 2006, and 2009. SETTING: Academic and community-based nonrehabilitation hospitals from 44 states participating in the KID project. PARTICIPANTS: An estimated 508 children with either VWD or hemophilia. INTERVENTIONS: Tonsillectomy with and without adenoidectomy, and subsequent hospitalization. MAIN OUTCOME MEASURE: Treatment for posttonsillectomy hemorrhage. METHODS: We extracted all cases of tonsillectomy, adenotonsillectomy, and posttonsillectomy hemorrhage in patients with VWD or hemophilia using International Classification of Diseases, Ninth Revision diagnostic and procedure codes and applied national weights to estimate rates of posttonsillectomy hemorrhage. Using data regarding patient demographic characteristics, surgical indication, blood transfusion, hospital length of stay, and mortality, we conducted bivariate analyses to identify associations between possible risk factors and posttonsillectomy hemorrhage. RESULTS: Mean age was 7 years, and most patients were male, white, urbanites who had private insurance and underwent tonsillectomy for airway obstruction. The hemorrhage rate within 1 day of tonsillectomy (immediate) was 1.6% while the hemorrhage rate at least 2 days after tonsillectomy (delayed) was estimated at 15%. Delayed hemorrhage was associated with older age (P < .001) and was as high as 35% in children at least 16 years old. The rate of blood transfusion was 2.4%. There were no fatalities. CONCLUSIONS AND RELEVANCE: The frequency of immediate posttonsillectomy hemorrhage in children with VWD or hemophilia is similar to rates in the general healthy population. However, among children with VWD or hemophilia, the rate of delayed hemorrhage is substantially higher, especially in older children.

Prematurity and low birth weight as potential mediators of higher stillbirth risk in mixed black/white race couples.

OBJECTIVE: Although births of multiracial and multiethnic infants are becoming more common in the United States, little is known about birth outcomes and risks for adverse events. We evaluated risk of fetal death for mixed race couples compared with same race couples and examined the role of prematurity and low birth weight as potential mediating risk factors. METHODS: We performed a retrospective cohort analysis using data from the 1998-2002 California Birth Cohort to evaluate the odds of fetal death, low birth weight, and prematurity for couples with a mother and father who were categorized as either being of same or different racial groups. Risk of prematurity (birth prior to 37 weeks gestation) and low birth weight (<2500 g) were also tested to see if the model could explain variations among groups. RESULTS: The analysis included approximately 1.6 million live births and 1749 stillbirths. In the unadjusted model, compared with two white parents, black/black and black/white couples had a significantly higher risk of fetal death. When all demographic, social, biological, genetic, congenital, and procedural risk factors except gestational age and birth weight were included, the odds ratios (OR) were all still significant. Black/black couples had the highest level of risk (OR 2.11, CI 1.77-2.51), followed by black mother/white father couples (OR 2.01, CI 1.16-3.48), and white mother/black father couples (OR 1.84, CI 1.33-2.54). Virtually all of the higher risk of fetal death was explainable by higher rates of low birth weight and prematurity. CONCLUSIONS: Mixed race black and white couples face higher odds of prematurity and low birth weight, which appear to contribute to the substantially higher demonstrated risk for stillbirth. There are likely additional unmeasured factors that influence birth outcomes for mixed race couples.

Physician views on barriers to primary care for young adults with childhood-onset chronic disease.

OBJECTIVE: Growing numbers of children with severe chronic illnesses are surviving to adulthood. Little is known about what primary care physicians perceive as the resources for and barriers to providing primary care services for young adults who transfer care from pediatric to adult medicine practitioners. The objective of this study was to describe primary care physicians' resources for and barriers to caring for young adults with childhood-onset chronic diseases. METHODS: We conducted a national mailed survey of general internists and pediatricians to assess their office and specialty resources, attitudes toward, and barriers faced in treating young adult patients with childhood-onset chronic diseases. We then analyzed how these factors were associated with overall perceived quality of chronic illness care delivery. RESULTS: Overall response rate was 53% (1289 of 2434). Only half of general internists viewed themselves as readily able to provide for the primary care needs of young adults with childhood-onset chronic diseases. Half of the internists and 62% of pediatricians thought that it would be difficult for these young adults to find an adult-focused primary care provider. Both specialties reported lack of time and reimbursement as major barriers in providing primary care to transitioning patients. Good office systems for coordinating patient care and improved coordination with subspecialty resources were both associated with improved provider perception of providing high-quality chronic illness care. CONCLUSIONS: General pediatricians and internists report multiple barriers to providing care for adults with childhood-onset chronic diseases. Improvements in office-based support seem to be most associated with perceived quality of care delivery.

Operative mortality after renal transplantation--does surgeon type matter?

PURPOSE: Currently there are 64 accredited renal transplantation fellowships in Canada and the United States. Only 27% are limited in scope to kidney transplants. In the remaining fellowships the trainee learns to transplant multiple abdominal organs. Given this evolution to the multiorgan transplant surgeon, we evaluated the effect of the current training paradigm on practice patterns and outcomes for kidney transplants. MATERIALS AND METHODS: Using data from the Nationwide Inpatient Sample, discharge records for kidney transplants (6,674) were abstracted (1993 to 2003). Through the Nationwide Inpatient Sample unique surgeon identifier we determined the proportion of kidney transplants performed by multiorgan and kidney only transplant surgeons. We fit multilevel regression models to examine the relationship between surgeon type and transplant outcome. RESULTS: We identified 99 multiorgan and 196 kidney only transplant surgeons who performed 3,255 and 3,419 kidney transplants, respectively. Kidney only transplant surgeons were more likely than multiorgan surgeons to practice in nonteaching, private, for-profit hospitals (p <0.05). Unadjusted operative mortality was higher in patients treated by kidney only vs multiorgan transplant surgeons (1.7% vs 0.9%, p = 0.002). After adjusting for patient and hospital factors, those who underwent renal transplantation performed by multiorgan transplant surgeons had 55% lower odds of inpatient death (OR 0.45, 95% CI 0.26-0.76) vs kidney only transplant surgeons. CONCLUSIONS: Despite the current training paradigm, kidney only transplant surgeons have a prominent role in renal transplantation. However, given the current donor organ shortage and the implications for quality, the observed mortality difference suggests that additional investigation is needed to determine whether this role should be decreased.

Racial treatment trends in localized/regional prostate carcinoma: 1992-1999.

BACKGROUND: African-American men have a greater incidence of and mortality from prostate carcinoma compared with white men, and they are less likely to receive definitive therapy (radical prostatectomy or external beam radiation therapy). During the 1990s, the use of brachytherapy increased; however, its influence on racial and ethnic prostate carcinoma treatment trends remains unclear. The objective of this study was to describe treatment trends over the period 1992-1999 for localized/regional prostate carcinoma among white, Hispanic, and African-American men. METHODS: Using the Surveillance, Epidemiology, and End Results (SEER) registry data from 1992 through 1999, logistic regression models were used to determine whether the odds of receiving a specific treatment modality differed by racial and ethnic group and whether the differences changed over time when the models were adjusted for age, marital status, tumor grade, and SEER site (geography). RESULTS: The authors identified 142,340 men, including white men (81.6%), Hispanic men (6.4%), and African-American men (12.0%). Racial and ethnic differences in the rates of use of androgen-deprivation therapy/expectant management were noted; however, these differences appeared to lessen over time (P < 0.001). The rate of utilization of radical prostatectomy increased for Hispanic men, remained flat for African-American men, and decreased for white men. The utilization of brachytherapy and combination therapy increased for all three groups; however, the greatest increase in utilization was among white men. CONCLUSIONS: Further research will be required to determine the patient-level and provider-level variables that influence racial and ethnic treatment differences in localized/regional prostate cancer.

Assessment of torture and ill treatment of detainees in Mexico: attitudes and experiences of forensic physicians.

CONTEXT: International and Mexican human rights organizations have documented torture of detainees (ie, those held and indicted but not sentenced) in all 31 states and the Federal District of Mexico, but little is known about the attitudes and experiences of forensic physicians examining detainees. OBJECTIVE: To assess forensic physicians' experiences with and attitudes toward the nature and extent of torture and ill treatment among detainees examined in the previous year. DESIGN, SETTING, AND PARTICIPANTS: With the support of the Mexican Office of the Federal Attorney General, as part of a larger initiative to implement governmental reforms to eradicate torture in Mexico, an anonymous, self-administered, written, 80-item survey designed to assess correspondence of physician practices and attitudes with international standards on forensic investigation and documentation of torture was distributed to all federal forensic physicians (n = 115) and a convenience sample of state forensic physicians (n = 99) in Mexico in 2002. MAIN OUTCOME MEASURES: Estimates of the numbers of federal detainees medically evaluated and numbers of cases of suspected, alleged, and documented torture or ill treatment among federal detainees; factors interfering with documentation of forensic evidence; physicians' attitudes toward torture; measures that would help them document torture; and recommendations for reform. RESULTS: Survey responses were received from 93 (81%) federal and 91 (92%) state forensic physicians. Forty-nine percent of federal physicians and 58% of state physicians reported that torture is a severe problem for detainees in Mexico. Federal physicians estimated that they had conducted 26 445 to 30 650 or more medical evaluations of the 13 000 federal detainees in the past year and that between 1658 and 4850 of these detainees had alleged torture; these physicians also estimated that they had documented evidence of torture in a range of 285 to 1090 cases. Forty percent of respondents had suspected torture and/or ill treatment of detainees examined during the previous year, 64% had examined detainees who alleged these practices had occurred, and 49% had documented forensic evidence of torture among these detainees. Respondents reported that lack of photographic equipment and services (58%), inadequate monitoring and accuracy of medical examinations (36%), inadequate documentation of torture (29%), limitations in their training (28%), fear of reprisals for documenting torture (23%), and fear of coercion by police officials (18%) are factors that interfere with documentation of torture and ill treatment of detainees. Respondents further reported the need for additional training (98%), standardized protocols and documentation procedures for use in cases of alleged or suspected torture and/or ill treatment (81%), and monitoring to ensure the quality and accuracy of medical evaluations (95%). CONCLUSIONS: Torture and ill treatment of detainees is a major problem in Mexico facilitated by multiple medical and legal factors. Mexican forensic physicians support measures to improve forensic documentation of torture and ill treatment of detainees.