Lack Of Private Health Insurance Research Articles

Financial hardship screening among Native American patients with cancer: a qualitative analysis

BackgroundCancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients.MethodsWe conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software.ResultsWe interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient’s financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS.ConclusionsWe identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

Risk Factors for Missed Follow-up Appointments among Facial Trauma Patients.

A retrospective case-control study was performed to characterize the rate of missed follow-up appointments after facial trauma and identify associated risk factors.Follow-up appointments for facial trauma over a 3-month period at a single, safety net hospital were analyzed. Appointment-specific, sociodemographic, trauma, and management data were compared between cases (missed appointments) and controls (attended appointments). Univariate testing and multivariable logistic regression were employed.A total of 116 cases and 259 controls were identified, yielding a missed appointment rate of 30.9% (116/375). Missed appointments were significantly associated with initial clinic appointments compared to return visits (odds ratio [OR] 2.21 [1.38-3.54]), afternoon visits compared to morning (OR 3.14 [1.94-5.07]), lack of private health insurance (OR 2.91 [1.68-5.18]), and presence of midface fractures (OR 2.04 [1.28-3.27]). Missed appointments were negatively associated with mandible fractures (OR 0.56 [0.35-0.89]), surgical management (OR 0.48 [0.30-0.77]), and the presence of nonremovable hardware (OR 0.39 [0.23-0.64]). Upon multivariable logistic regression, missed appointments remained independently associated with afternoon visits (adjusted OR [aOR] 1.95 [1.12-3.4]), lack of private health insurance (aOR 2.73 [1.55-4.8]), and midface fractures (aOR 2.09 [1.21-3.59]).Nearly one-third of facial trauma patients missed follow-up appointments, with the greatest risk among those with afternoon appointments, lacking private health insurance, and with midface fractures.

Barriers to resection following neoadjuvant chemotherapy for resectable pancreatic adenocarcinoma: A national and local perspective.

Neoadjuvant chemotherapy (NAC) use for pancreatic ductal adenocarcinoma (PDAC) has increased, but some patients never get resection following NAC. Data from January 2012 to December 2019 for all clinically resectable patients across two health networks were utilized, as well as data from the ACS NCDB registry. Univariate testing, multivariable logistic regression, and survival analyses were employed to evaluate failure to resection after neo-adjuvant chemotherapy. Of the 10 007 registry patients eligible for resection, the resected group was younger (64.6 vs. 69.5 years; p < 0.001) and had a slightly lower mean comorbidity index (0.41 vs. 0.45; p < 0.001) than the nonsurgical group. The nonsurgical group was composed of a higher percentage of Black and Hispanic patients (17.5 vs. 13.1%; p < 0.001). After adjusting for age and comorbidities, the factors associated with decreased probability of resection after NAC were evaluation at a community hospital (OR 2.4), Black or Hispanic race (OR 1.6), areas of increased high school drop-out rates (OR 1.4), and lack of private health insurance (OR 1.3). The median overall survival for nonsurgery was markedly worse than the surgical cohort (10.6 vs. 26.6 months; p < 0.001). The most frequent reasons for a lack of definitive resection were operative upstaging to unresectable (39.6%), patient preference (14.5%), progression on NAC (13.2%), deconditioning or comorbidity severity (12.5%), and nonreferral to a surgeon (8.8%). Racial, economic, and educational disparities have a considerable influence on the successful completion of a neoadjuvant approach for resectable PDAC. A comprehensive closed or highly collaborative/communicative multidisciplinary neoadjuvant program is optimal for treatment success and completion.

Patient experience and pain outcomes among Black women with early-stage breast cancer after mastectomy.

e13751 Background: Racial pain disparities in breast cancer (BC) are well-described and persist despite prior trials to improve disparate pain outcomes. We previously found Black women (BW) reported more pain severity (PS) and interference with life (PI) after breast surgery compared to White women. Pain expression is multifactorial, and structural factors affect the ability to report and control pain. Perceived discrimination is associated with mistrust of medical providers, which affects clinical outcomes. Their impact on pain is understudied. We evaluated the association between discrimination, trust, and pain among BW with early-stage BC after mastectomy. Methods: BW with stage 0-III BC who had mastectomy ≤2 years of enrollment at academic and safety net hospitals in Houston, TX and Atlanta, GA, completed a demographic survey, Brief Pain Inventory (BPI), Discrimination in Medical Settings Scale (DMS), and Trust in Physician Scale (TPS). In BPI, worst, least, and average PS were reported from 0-10. PI from 0-10, pain treatments, and % relief were reported. DMS and TPS questions were on a 5-point Likert scale. We performed chart review to obtain baseline clinical data related to BC diagnosis, treatment and comorbidities. PI and DMS were scored as a mean of the total items of each survey. Mean Trust and Mistrust scores used means of TPS questions related to each category. Higher scores mean more PS, PI, discrimination, trust, or mistrust. We used ANOVA to examine associations between categorical variables and Pearson correlation coefficient for continuous variables. We performed univariate linear regression and multi-linear regression between specific variables and outcomes, accounting for collinearity. Results: Of the 77 BW surveyed, 66.2% received chemotherapy. 47.2% had a household income &lt; $25,000, and 40.3% had private health insurance. PS, PI, DMS, and trust scores are shown (Table). Univariate analysis showed an association between DMS and mistrust (p=0.01), lower income and higher PS (p=0.01) and PI (p=0.04), and insurance status and PS (p=0.02) and PI (p=0.02). Associations between mistrust or DMS and pain were not statistically significant. A multivariate analysis with DMS as outcome showed an association with mistrust (p=0.04). Multivariate analysis also showed receipt of chemotherapy was associated with higher PS (p=0.02) and PI (p=0.03). Conclusions: BW have moderate pain up to 2 years following mastectomy. Participants reported low levels of discrimination and high trust. More discrimination was associated with more physician mistrust, but not PS or PI. Lower income and lack of private health insurance were associated with higher PS and PI. Future studies should address discrimination and trust in clinical settings and financial barriers to pain control. [Table: see text]

Does treatment at a level I trauma center reduce disparities in patient outcomes for open tibia fractures? A retrospective analysis of the National trauma Databank

BackgroundRace and insurance status are independent predictors of healthcare outcomes following lower-extremity trauma. Level 1 trauma centers show better outcomes overall, but it is has not been extensively studied as to whether they specifically lower complication rates and shorten length of stay in those with Black race, with low socioeconomic status, and/or a lack of private health insurance. We performed a study with the objective of determining whether Level I trauma centers can improve the complication rate of those shown to be at high risk of experiencing adverse outcomes due to socioeconomic differences. HypothesisLevel 1 trauma centers will be successful in mitigating the disparity in complication rates and length of stay associated with racial and socioeconomic differences among trauma patients experiencing an open tibia fracture. Patients and methodsThe National Trauma Databank was reviewed from 2008 to 2015, identifying 81,855 encounters with an open tibia fracture, and 33,047 at a Level I trauma center. Regression models determined effects of race and insurance status on outcomes by trauma center while controlling for confounders. ResultsBlack race [OR 1.36, 95% CI, 1.17–1.58; p < 0.05] and “other” race [OR 1.28, 95% CI, 1.07–1.52; p < 0.05] were associated with higher odds of injury-specific complications. Patients without private insurance and of non-White or Black race in comparison to White patients had a significantly longer length of stay [coefficient 1.66, 95% CI, 1.37–1.94; p < 0.001]. These differences persisted in patients treated at an American College of Surgeons (ACS) Level I trauma center. DiscussionTreatment at an ACS Level I trauma center did not reduce the independent effects of race and insurance status on outcomes after open tibia fracture, emphasizing the need to recognize this disparity and improve care for at-risk populations.

Barriers to Breast Cancer-Screening Adherence in Vulnerable Populations.

Breast cancer screening through periodic mammography has been effective in decreasing mortality and reducing the impact of this disease. However, adherence to screening does not meet the desired expectations from all populations. The main objective of this review is to explore the barriers that affect adherence to breast cancer-screening programs in vulnerable populations according to race and/or ethnicity in order to propose measures to reduce the lack of adherence. We conducted a search of publications in the PubMed Central and Scopus databases. The eligible criteria for the articles were as follows: original quantitative studies appearing in SJR- and/or JCR-indexed journals from 2016 to 2021 in English or Spanish. Most of them present common barriers, such as race/ethnicity (47%), low socioeconomic (35.3%) and educational levels (29.4%), no family history of cancer and being single (29.4%), medical mistrust and a health information gap (23.5%), lack of private health insurance (17.6%) and not having annual health checks (17.6%). The target populations with the lowest adherence were Black, Asian, Hispanic and foreign women. Implementing awareness campaigns focused on these populations should be promoted, as well as working on diversity, cultural acceptance and respect with healthcare workers, in order to improve breast cancer-screening adherence worldwide.

Predictors of Missed Follow-up Visits in the National Traumatic Brain Injury Model Systems Cohort Study

ObjectiveTo identify key variables that could predict risk of loss to follow-up (LTFU) in a nationally funded longitudinal database of persons with traumatic brain injury. DesignSecondary analysis of a prospective longitudinal cohort study. SettingTraumatic Brain Injury Model System (TBIMS) Centers in the US. ParticipantsA total of 17,956 TBIMS participants (N=17,956) with interview status data available were included if eligible for 1-, 2-, 5-, 10-, 15-, or 20-year follow-ups between October 31, 1989, and September 30, 2020. InterventionsNot applicable. Main Outcome MeasuresFollow-up data collection completion status at years 1, 2, 5, 10, 15, and 20. ResultsInformation relevant to participants’ history, injury characteristics, rehabilitation stay, and patterns of follow-up across 20 years were considered using a series of logistic regression models. Overall, LTFU rates were low (consistently <20%). The most robust predictors of LTFU across models were missed earlier follow-ups and demographic factors including Hispanic ethnicity, lower education, and lack of private health insurance. ConclusionsEfforts to retain participants in such social disadvantaged or minority groups are encouraged given their disproportionate rate of LTFU. Repeated attempts to reach participants after a previously missed assessment are beneficial because many participants that missed 1 or more follow-ups were later recovered.

Transplant Still Relevant Even in the Era of Novel Treatments for Multiple Myeloma — National Cancer Database Analysis

Background: Survival of patients with multiple myeloma has significantly improved over the last decade. Several new treatments have been approved for the treatment of myeloma in the last few years that have changed its landscape. Newer drugs with deeper and durable responses have challenged the role of autologous stem cell transplant (auto SCT) in the management of myeloma.Aim: We aimed to study the impact of auto SCT and several other demographic and treatment related factors on the outcome of myeloma by analyzing the data from National Cancer Database (NCDB).Materials and Methods: Data was analyzed from 9218 patients (both men and women aged >18 years) who were diagnosed with multiple myeloma and registered in NCDB between 2010 and 2013 with follow up to the end of 2014. Factors such as age, race, gender, income, education, Charlson comorbidity index (CCI), distance traveled to get cancer care, treatment facility, health insurance and type of treatment (chemotherapy only versus chemotherapy followed by auto SCT) were investigated and the primary outcome was overall survival.Results: The median age of the patients was 66 years. Fifty five percent of patients were male. Around 56% of the patients were older than 65 years. Among the patients reviewed, 73% were Caucasian and 24% African American. As assessed by Charlson comorbidity index, 75% of patients had no major medical comorbidities. Forty six percent of patients received treatment at a facility different from where they were diagnosed with myeloma. Around one third of the patients were treated at an academic facility and the rest at either a community cancer program or comprehensive community cancer program. Treatment was initiated within 2 weeks of diagnosis in 36% of the patients whereas 21% of patients could not start treatment until after 6 weeks from diagnosis. Approximately 53% of patients had health care funding by Medicare, 35% had private insurance, 7% had Medicaid and around 5% of the patients were uninsured. Around 11% of the patients received auto SCT as part of treatment. In a multivariate analysis, after adjusting for other variables, receiving auto SCT was a statistically significant predictor of overall survival. A 71% improvement in survival was observed in patients who received auto SCT for myeloma compared to those who did not. Male gender, age older than 65 years, African American race, major comorbidities as determined by CCI, change of facility for treatment were other significant predictors of survival in the multivariate analysis. Females were 11% less likely to die of myeloma compared to males. Patients older than 65 years had 59% increased risk of dying compared to patients younger than 40 years. African Americans had 17% reduced risk of death compared to Caucasians. Myeloma patients with 1 and 2 medical comorbidities had 31% and 75% increased risk of death respectively compared to those with no comorbidities. Receiving treatment at a facility different from that of diagnosis had a very small survival advantage. Patients with Medicaid, Medicare and no health insurance had 16%, 29% and 19% increased risk of death compared to those with private insurance respectively. Level of education of patients, annual income and distance traveled to the treatment facility did not have any significant impact on the overall survival in multivariate analysis.Conclusions: Even in the era of novel drugs for the treatment of myeloma, auto SCT still has a significant role and offers overall survival benefit according to our NCDB analysis. Male gender, elderly age, 1 or more medical comorbidities, lack of private health insurance were shown to be predictors of poor overall survival. DisclosuresNo relevant conflicts of interest to declare.

Socio-environmental determinants of the delay in the first dental visit: results of two population-based cohort studies in Brazil.

The objective of this study was to describe the timing of the first dental visit and investigate the association of socioeconomic and behavioral factors with dental visit delay among 10/11-year-old children from two live-birth population cohorts with extremely contrasting socioeconomic profiles. Follow-up data (2004-2005) from cohorts of Ribeirão Preto (RP) (n=790) and São Luís (SL) (n=673) were evaluated. Delay in dental visit was defined as not visiting a dentist before the age of 7. Covariates included family socioeconomic characteristics, mother-related health behavior, and child-related characteristics. Prevalence ratios with robust standard errors were estimated. In both cohorts, less than 5% of children had visited a dentist before the age of two and about 35% of them had not visited a dentist before the age of seven. Lower mother’s schooling and lack of private health insurance were associated with the delay in first dental visit for both cohorts. A small number of mother's prenatal care visits and being from a single-father family or a family without parents were only associated in the RP cohort, while having ≥4 siblings and lifetime dental pain were associated in the SL cohort. The association with dental pain probably reveals a preventive care-seeking behavior. Therefore, the percentage of delayed first dental visit of children was very high even among those with the most educated mothers. Further studies are necessary to analyze recent changes and underlying factors related to access to first dental visit after the implementation of the National Oral Health Policy in 2006.

The early natural history of albuminuria in young adults with youth-onset type 1 and type 2 diabetes

AimsTo determine among adolescents and young adults with youth-onset type 1 diabetes and type 2 diabetes the rates and risk factors for albuminuria regression and progression. MethodsData from SEARCH, a longitudinal observational study of youth-onset type 1 diabetes (N = 1316) and type 2 diabetes (N = 143) were analyzed. Urine albumin:creatinine ratio (UACR) was measured from random urine specimens at baseline and follow-up visits (mean 7 years later). Albuminuria regression was defined as halving of baseline UACR when baseline UACR was ≥30 μg/mg; progression was defined as doubling of baseline UACR when follow-up UACR was ≥30 μg/mg, respectively. Multivariable regression assessed risk factors associated with low-risk albuminuria category (combined persistently-low albuminuria and regression) versus moderate-risk albuminuria category (combined persistently-high albuminuria and progression). ResultsAlbuminuria progression was more common in type 2 diabetes versus type 1 diabetes (15.4% versus 6.0%, p<0.001). Moderate-risk albuminuria was associated with increasing HbA1c (adjusted OR (aOR) = 1.3, 95% CI 1.1–1.6) and lack of private health insurance (aOR = 2.7, 95%CI 1.1–6.5) in type 1 diabetes; and African American race (OR = 4.6, 95% CI 1.2–14.2), lower estimated insulin sensitivity score (aOR = 2.1, 95% CI 1.4–3.3), baseline UACR (aOR = 3.2, 95% CI 1.7–5.8), and follow-up estimated glomerular filtration rate (eGFR) (10-unit increase aOR = 1.3, 95% CI 1.0, 1.5) in type 2 diabetes. ConclusionsIn the first decade of diabetes duration, kidney complications in type 2 diabetes are significantly more aggressive than in type 1 diabetes and may be associated with less modifiable risk factors including race, insulin sensitivity, and eGFR. Early interventions may help reduce long-term kidney complications.

The Prevalence and Demographic Associations of Presenting Near-Vision Impairment Among Adults Living in the United States

To estimate prevalence of presenting near-vision impairment (PNVI) among people aged ≥50 years in the United States (US) and examine associations with sociodemographic characteristics. Cross-sectional study. A total of 11 016 of 12 781 (88.5%) US adults aged ≥50 years participated in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2008 with recorded near visual acuity. PNVI was defined as presenting near vision worse than 20/40; functional near-vision impairment (FNVI) was defined as at least "moderate difficulty" with either reading newsprint or near work. Prevalence of PNVI and FNVI were estimated accounting for National Health and Nutrition Examination Survey multistage probability sampling design. Multivariable regression models were used to determine sociodemographic characteristics associated with PNVI. A total of 13.6% of participants had PNVI, with 25.9% reporting concurrent FNVI. Higher odds of PNVI was associated with nonwhite race, older age, male sex, less than high school education, lack of private health insurance, income less than poverty level, lacking/not using near-vision correction at time of examination, and impaired distance vision. Although the majority of participants with PNVI (82.9%) had normal distance vision or uncorrected refractive error, less than half (46.1%) used near-vision correction. Not using near correction was associated with nonwhite race, younger age, male sex, and lack of access to health care. Approximately 1 in 8 Americans aged ≥50 years have PNVI, with 1 in 4 reporting concurrent FNVI. Demographic factors shown to be important in access to eye care likely influence PNVI and utilization of near-vision correction in the US. As the majority of PNVI is likely correctable with spectacles, allocation of resources to provide corrective lenses to those in need likely has great public health implications.

Age at Surgery and Outcomes of an Undescended Testis

Undescended testis (UDT) is the most common genital anomaly in boys. Current guidelines recommend surgery before 12 months of age to maximize fertility and potentially reduce the risk of future malignancy. We investigated the prevalence of UDT and examined rates of surgery and age at surgery in an Australian population. UDT was identified from all live-born infants in New South Wales, Australia, from 2001 to 2011 using routinely collected record-linked birth and hospital data. The prevalence of UDT, surgery rates, age at surgery, postsurgical outcomes, and risk factors for surgery performed later than the recommended age were evaluated. There were 10 875 (2.1%) boys with a recorded diagnosis of UDT. Corrective surgery was performed in 4980 (45.8%), representing a cumulative prevalence of 9.6 per 1000 male births. Five percent of surgeries were orchidectomies, and 9% of boys had revision surgery. Median age at surgery was 16.6 months (interquartile range 11.8 to 31.0 months), decreasing from 21 months for boys born in 2001 to 13 months for boys born in 2010. Among those boys having surgery before 36 months (n = 3897), 67% had corrective surgery after the recommended 12 months of age; socioeconomic disadvantage, regional/remote area of residence, and lack of private health insurance were risk factors for having corrective surgery after 12 months. One in 50 boys born are diagnosed with UDT; two-thirds had no report of corrective surgery. The age at surgery is decreasing; however, two-thirds of surgeries are performed after 12 months of age.

Lack of private health insurance is associated with higher mortality from cancer and other chronic diseases, poor diet quality, and inflammatory biomarkers in the United States

ObjectiveThe lack of health insurance reduces access to care and often results in poorer health outcomes. The present study simultaneously assessed the effects of health insurance on cancer and chronic disease mortality, as well as the inter-relationships with diet, obesity, smoking, and inflammatory biomarkers. We hypothesized that public/no insurance versus private insurance would result in increased cancer/chronic disease mortality due to the increased prevalence of inflammation-related lifestyle factors in the underinsured population. MethodsData from the Third National Health and Nutrition Examination Survey participants (NHANES III;1988–1994) were prospectively examined to assess the effects of public/no insurance versus private insurance and inflammation-related lifestyle factors on mortality risk from cancer, all causes, cardiovascular disease (CVD) and diabetes. Cox proportional hazards regression was performed to assess these relationships. ResultsMultivariate regression analyses revealed substantially greater risks of mortality ranging from 35% to 245% for public/no insurance versus private insurance for cancer (HR=1.35; 95% CI=1.09,1.66), all causes (HR=1.54; 95% CI=1.39,1.70), CVD (HR=1.62; 95% CI=1.38,1.90) and diabetes (HR=2.45; 95% CI=1.45,4.14). Elevated CRP, smoking, reduced diet quality and higher BMI were more prevalent in those with public insurance, and were also associated with increased risks of cancer/chronic disease mortality. DiscussionInsurance status was strongly associated with cancer/chronic disease mortality after adjusting for lifestyle factors. The results suggest that inadequate health insurance coverage results in a substantially greater need for preventive strategies that focus on tobacco control, obesity, and improved dietary quality. These efforts should be incorporated into comprehensive insurance coverage programs for all Americans.

Factors Predictive of Emergency Department Visits and Hospitalization Following Thyroidectomy and Parathyroidectomy.

This study aimed to determine the incidence and risk factors for emergency department (ED) visits and unplanned hospitalization after thyroid and parathyroid surgery. A retrospective study of all patients who underwent thyroidectomy or parathyroidectomy from 2007 to 2014 was conducted to assess for ED visits or unplanned hospitalization within 30 days after surgery. Uni- and multivariate analyses were used to identify risk factors for ED visits and hospitalization. Of 864 patients who underwent thyroidectomy (n = 673) or parathyroidectomy (n = 191), 96 (11.1 %) had an ED visit and 41 (4.7 %) were hospitalized within 30 days after surgery. Univariate analysis showed hypocalcemia (p = 0.001), younger age (p = 0.02), total thyroidectomy (p = 0.01), and lack of private health insurance (p = 0.005) to be predictive of an ED visit and hypocalcemia (p = 0.0001), Hashimoto's thyroiditis (p = 0.049), total thyroidectomy (p = 0.005), and African American race (p = 0.03) were predictive of hospitalization after thyroidectomy. Multivariate analysis showed younger age (odds ratio [OR] 1.5 per 10-year decrease in age; p = 0.002; 95 % confidence interval [CI] 1.1-1.8) and Medicare insurance (OR 2.7; p = 0.01; 95 % CI 1.3-5.7) to be independently associated with an ED visit, and hypocalcemia (OR 4.7; p < 0.001; 95 % CI 2.2-11.0) was the only independent factor associated with hospitalization after thyroidectomy. Univariate analysis showed hypocalcemia, renal hyperparathyroidism, and multiglandular disease to be predictive of an ED visit and hospitalization after parathyroidectomy. The sample size for parathyroidectomy was too small for multivariate analysis. Targeted strategies for transitions of care for patients with postoperative hypocalcemia may help to reduce ED visits and hospitalization after thyroidectomy and parathyroidectomy.

Pressure to change drinking behavior: An exploratory analysis of US general population subgroups.

General population studies have shown that pressure from others to change drinking can come from different sources. Receipt of informal pressure (IP) and formal pressure (FP) is known to vary by quantity and consequences of drinking, but less is known about how pressure varies among subgroups of the population. This exploratory study utilizes data from the National Alcohol Surveys from 1995-2010 (N=26,311) and examines associations between receipt of pressure and subgroups of drinkers. Increased relative risk of receiving IP and FP were observed for individuals reporting an arrest for driving after drinking and illicit drug use while poverty and lack of private health insurance increased risk of receipt of formal pressures. Regular marijuana use increased IP. The subgroups that were studied received increased pressures to change drinking behavior, though disentangling the societal role of pressure and how it may assist with interventions, help seeking, and natural recovery is needed.

Trends in the Prevalence of Ketoacidosis at Diabetes Diagnosis: The SEARCH for Diabetes in Youth Study

To estimate temporal changes in the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 or type 2 diabetes in youth and to explore factors associated with its occurrence. Five centers identified incident cases of diabetes among youth aged 0 to 19 years starting in 2002. DKA presence was defined as a bicarbonate level <15 mmol/L and/or a pH <7.25 (venous) or <7.30 (arterial or capillary) or mention of DKA in the medical records. We assessed trends in the prevalence of DKA over 3 time periods (2002-2003, 2004-2005, and 2008-2010). Logistic regression was used to determine factors associated with DKA. In youth with type 1 diabetes (n = 5615), the prevalence of DKA was high and stable over time (30.2% in 2002-2003, 29.1% in 2004-2005, and 31.1% in 2008-2010; P for trend = .42). Higher prevalence was associated with younger age at diagnosis (P < .0001), minority race/ethnicity (P = .019), income (P = .019), and lack of private health insurance (P = 008). Among youth with type 2 diabetes (n = 1425), DKA prevalence decreased from 11.7% in 2002-2003 to 5.7% in 2008-2010 (P for trend = .005). Higher prevalence was associated with younger age at diagnosis (P = .001), minority race/ethnicity (P = .013), and male gender (P = .001). The frequency of DKA in youth with type 1 diabetes, although stable, remains high, indicating a persistent need for increased awareness of signs and symptoms of diabetes and better access to health care. In youth with type 2 diabetes, DKA at onset is less common and is decreasing over time.

The Effects of Race and Other Socioeconomic Factors on Health Service Use Among American Military Veterans

This study examined the extent to which racial disparities in service utilization exist in veterans (VA) and non-VA health care systems. An observational study design was used with a nationally representative sample of veterans. Logistic regression models were constructed using sociodemographic characteristics, health insurance and benefits, and health status as predictors of health service use in both VA and non-VA health care systems. A population weighted sample of 19,270 veterans from the 2001 National Survey of Veterans was used, which included 17,004 (88.24%) White, 1,864 (9.15%) African American, 414 (2.15%) Native American/Alaskan Native, and 87 (0.45%) Asian American/Pacific Islander veterans. Results showed that use of the VA health care system was not associated with race, but was associated with VA disability compensation, lack of private health insurance, and greater health care need. Contrarily, in non-VA healthcare systems, veterans who were racial minorities, less educated, and without private health insurance were less likely to use services. Together, these findings demonstrate the socioeconomic context in which health disparities exist and suggest the influence of health insurance on racial disparities in service utilization.

Diabetic Ketoacidosis at Diabetes Onset: Still an All Too Common Threat in Youth

To define the demographic and clinical characteristics of children at the onset of type 1 diabetes (T1D), with particular attention to the frequency of diabetic ketoacidosis (DKA). The Pediatric Diabetes Consortium enrolled children with new-onset T1D into a common database. For this report, eligible subjects were aged <19 years, had a pH or HCO(3) value recorded at diagnosis, and were positive for at least one diabetes-associated autoantibody. Of the 1054 children enrolled, 805 met the inclusion criteria. A pH of <7.3 and/or HCO(3) value of <15 mEq/L defined DKA. Data collected included height, weight, hemoglobin A1c, and demographic information (eg, race/ethnicity, health insurance status, parental education, family income). The 805 children had a mean age of 9.2 years, 50% were female; 63% were non-Hispanic Caucasian. Overall, 34% of the children presented in DKA, half with moderate or severe DKA (pH <7.2). The risk for DKA was estimated as 54% in children aged <3 years and 33% in those aged ≥ 3 years (P = .006). In multivariate analysis, younger age (P = .002), lack of private health insurance (P < .001), African-American race (P = .01), and no family history of T1D (P = .001) were independently predictive of DKA. The mean initial hemoglobin A1c was higher in the children with DKA compared with those without DKA (12.5% ± 1.9% vs 11.1% ± 2.4%; P < .001). The incidence of DKA in children at the onset of T1D remains high, with approximately one-third presenting with DKA and one-sixth with moderate or severe DKA. Increased awareness of T1D in the medical and lay communities is needed to decrease the incidence of this life-threatening complication.

Survival from breast cancer: an analysis of Australian data by surgeon case load, treatment centre location, and health insurance status

Early invasive breast cancer data from the Australian National Breast Cancer Audit were used to compare case fatality by surgeon case load, treatment centre location and health insurance status. Deaths were traced to 31 December 2007, for cancers diagnosed in 1998-2005. Risk of breast cancer death was compared using Cox proportional hazards regression. When adjustment was made for age and clinical risk factors: (i) the relative risk of breast cancer death (95% confidence limit) was lower when surgeons' annual case loads exceeded 20 cases, at 0.87 (0.76, 0.995) for 21-100 cases and 0.83 (0.72, 0.97) for higher case loads. These relative risks were not statistically significant when also adjusting for treatment centre location (P ≥ 0.15); and (ii) compared with major city centres, inner regional centres had a relative risk of 1.32 (1.18, 1.48), but the risk was not elevated for more remote sites at 0.95 (0.74, 1.22). Risk of death was not related to private insurance status. Higher breast cancer mortality in patients treated in inner regional than major city centres and in those treated by surgeons with lower case loads requires further study.

Desigualdades contextuais e individuais da prevalência de dor dentária em adultos e idosos no Brasil

This study aimed to assess the prevalence of dental pain among adults and older people living in Brazil's State capitals. Information was gathered from the Telephone Survey Surveillance System for Risk and Protective Factors for Chronic Diseases (VIGITEL) in 2009 (n = 54,367). Dental pain was the outcome. Geographic region, age, gender, race, schooling, private health coverage, smoking, and soft drink consumption were the explanatory variables. Multilevel Poisson regression models were performed. Prevalence of dental pain was 15.2%; Macapá and São Luís had prevalence rates greater than 20%; all capitals in the South and Southeast, plus Cuiabá, Campo Grande, Maceió, Recife, and Natal had prevalence rates less than 15%. Factors associated with increased prevalence of dental pain were the North and Northeast regions, female gender, black/brown skin color, lack of private health insurance, smoking, and soft drink consumption. Dental pain is a public health problem that should be monitored by health surveillance systems.