Usual Place Of Care Research Articles

Racial and Ethnic Disparities in Vaccination Coverage Among Adult Populations in the U.S.

Reducing racial/ethnic disparities in immunization rates is a compelling public health goal. Disparities in childhood vaccination rates have not been observed in recent years for most vaccines. The objective of this study is to assess adult vaccination by race/ethnicity in the U.S. The 2012 National Health Interview Survey was analyzed in 2014 to assess adult vaccination by race/ethnicity for five vaccines routinely recommended for adults: influenza, tetanus, pneumococcal (two vaccines), human papilloma virus, and zoster vaccines. Multivariable logistic regression analysis was performed to identify factors independently associated with all adult vaccinations. Vaccination coverage was significantly lower among non-Hispanic blacks, Hispanics, and non-Hispanic Asians compared with non-Hispanic whites, with only a few exceptions. Age, sex, education, health insurance, usual place of care, number of physician visits in the past 12 months, and health insurance were independently associated with receipt of most of the examined vaccines. Racial/ethnic differences narrowed, but gaps remained after taking these factors into account. Racial and ethnic differences in vaccination levels narrow when adjusting for socioeconomic factors analyzed in this survey, but are not eliminated, suggesting that other factors that are associated with vaccination disparities are not measured by the National Health Interview Survey and could also contribute to the differences in coverage. Additional efforts, including systems changes to ensure routine assessment and recommendations for needed vaccinations among adults for all racial/ethnic groups, are essential for improving vaccine coverage.

Patients' Satisfaction with and Preference for Telehealth Visits.

One-quarter of U.S. patients do not have a primary care provider or do not have complete access to one. Work and personal responsibilities also compete with finding convenient, accessible care. Telehealth services facilitate patients' access to care, but whether patients are satisfied with telehealth is unclear. We assessed patients' satisfaction with and preference for telehealth visits in a telehealth program at CVS MinuteClinics. Cross-sectional patient satisfaction survey. Patients were aged ≥18 years, presented at a MinuteClinic offering telehealth in January-September 2014, had symptoms suitable for telehealth consultation, and agreed to a telehealth visit when the on-site practitioner was busy. Patients reported their age, gender, and whether they had health insurance and/or a primary care provider. Patients rated their satisfaction with seeing diagnostic images, hearing and seeing the remote practitioner, the assisting on-site nurse's capability, quality of care, convenience, and overall understanding. Patients ranked telehealth visits compared to traditional ones: better (defined as preferring telehealth), just as good (defined as liking telehealth), or worse. Predictors of preferring or liking telehealth were assessed via multivariate logistic regression. In total, 1734 (54%) of 3303 patients completed the survey: 70% were women, and 41% had no usual place of care. Between 94 and 99% reported being "very satisfied" with all telehealth attributes. One-third preferred a telehealth visit to a traditional in-person visit. An additional 57% liked telehealth. Lack of medical insurance increased the odds of preferring telehealth (OR = 0.83, 95% CI, 0.72-0.97). Predictors of liking telehealth were female gender (OR = 1.68, 1.04-2.72) and being very satisfied with their overall understanding of telehealth (OR = 2.76, 1.84-4.15), quality of care received (OR = 2.34, 1.42-3.87), and telehealth's convenience (OR = 2.87, 1.09-7.94) CONCLUSIONS: Patients reported high satisfaction with their telehealth experience. Convenience and perceived quality of care were important to patients, suggesting that telehealth may facilitate access to care.

FACTORS ASSOCIATED WITH END OF LIFE TRANSITION FOR OLDER ADULTS LIVING AT HOME: ANALYSIS OF CARERS' POST-BEREAVEMENT SURVEY

IntroductionTransfer to hospital in the last weeks of life is common for older adults. It is imperative to better understand factors associated with transition to enable older people to remain in their usual place of care.Aim(s) and method(s)To explore possible determinants of transition from home to institutional care settings in last weeks of life. Post-bereavement survey of carers to people aged over 75 who died in 2012 in the South of England (n=883). Main outcome is death at home versus hospital/care home (hospice deaths excluded) for decedents whose usual place of care was home. Exploration of socio-demographic factors and illness factors using multivariate modified Poisson regression.Results235 decedents spent most of the last 3 months of life at home. The majority died from non-malignant conditions (71.9%) with mean age 86 years. 51.1% died at home and 48.9% transitioned in the last 3 months to a hospital (44.7%) or care home (4.3%). Death outside usual place of care was independently associated with increasing age (85–90 years [PR=3.4; 95% CI 1.9–6.1] compared with 75–80 years), and severity of breathlessness (PR=1.9; 95% CI 1.2–3.4) and difficulty communicating (PR=2.0; 95% CI 1.5–2.8).Conclusion(s)Transition to hospital at the end of life is common for older adults living at home. Transition occurs most frequently for the oldest old and those with severe symptoms of breathlessness and difficulty communicating. To reduce reliance on hospital care at the end of life requires timely services responsive to increasing symptom distress and wider anticipation of end of life for adults of advanced age.

Serious Psychological Distress as a Barrier to Cancer Screening Among Women

BackgroundThe purposes of the study were to examine the association of serious psychological distress (SPD) and cancer-screening utilization in a nationally representative sample of women aged 40 to 74 years and to identify barriers and facilitating factors to breast and cervical cancer screening among women with SPD. MethodsWomen aged 40 to 74 (n = 17,770) were selected from the Household Component of Medical Expenditure Panel Survey series of 2007, 2009, and 2011. SPD was defined as a score of 13 of higher on the Kessler Psychological Distress Scale–6 items (K6 scale) of nonspecific psychological distress. Logistic regression was conducted to examine the association between SPD and up-to-date cancer screening. FindingsWomen with SPD had significantly lower rates of up-to-date clinical breast examination (67.56% vs. 81.93%), mammography (59.94% vs. 75.56%), and Pap smear (72.27% vs. 85.37%). In multivariate logistic regression analyses adjusting for sociodemographics, insurance, health behaviors, comorbidity, and service utilization, SPD was associated with nearly 40% decreased odds of being up to date with all three screening tests. Having a usual place of care, being physically active, and a greater number of past-year medical visits were strongly associated with higher odds of screening utilization among women with SPD. ConclusionsWomen with mental health problems have substantial risk for low use of routine breast and cervical cancer screenings. The K6 may be a useful tool to screen this risk factor. Frequent contact with the health care system among women with mental health problems opens up opportunities to reduce the mental illness-related disparities in utilization of cancer screening.

Awareness of cancer susceptibility genetic testing: the 2000, 2005, and 2010 National Health Interview Surveys.

Genetic testing for several cancer susceptibility syndromes is clinically available; however, existing data suggest limited population awareness of such tests. To examine awareness regarding cancer genetic testing in the U.S. population aged ≥25 years in the 2000, 2005, and 2010 National Health Interview Surveys. The weighted percentages of respondents aware of cancer genetic tests, and percent changes from 2000-2005 and 2005-2010, overall and by demographic, family history, and healthcare factors were calculated. Interactions were used to evaluate the patterns of change in awareness between 2005 and 2010 among subgroups within each factor. To evaluate associations with awareness in 2005 and 2010, percentages were adjusted for covariates using multiple logistic regression. The analysis was performed in 2012. Awareness decreased from 44.4% to 41.5% (p<0.001) between 2000 and 2005, and increased to 47.0% (p<0.001) in 2010. Awareness increased between 2005 and 2010 in most subgroups, particularly among individuals in the South (pinteraction=0.03) or with a usual place of care (pinteraction=0.01). In 2005 and 2010, awareness was positively associated with personal or family cancer history and high perceived cancer risk, and inversely associated with racial/ethnic minorities, age 25-39 or ≥60 years, male gender, lower education and income levels, public or no health insurance, and no provider contact in 12 months. Despite improvement from 2005 to 2010, ≤50% of the U.S. adult population was aware of cancer genetic testing in 2010. Notably, disparities persist for racial/ethnic minorities and individuals with limited health care access or income.

Abstract P160: Conflicting Associations of Acculturation and Cardiovascular Risk in Hispanics in the National Health and Nutrition Examination Survey 1999-2010: What Are We Measuring?

Background: Acculturation is the process by which immigrant groups adopt the cultural practices and values of the host country. Research has produced conflicting results in the association between acculturation and cardiovascular disease (CVD) risk among Hispanics. The National Health and Nutrition Examination Survey (NHANES) has collected multiple acculturation measures. We evaluated the hypothesis that the acculturation measure utilized impacts the association with CVD risk. Methods: The following measures of acculturation were available: Nativity, Language spoken at home (‘mostly English,’ ‘Equal English/Spanish,’ ‘Mostly Spanish’), Years in the US (0-5, 6-10, 11-15, 16-20, &gt;20), and US citizenship. The validated Short Acculturation Scale (SAS) was only used between 1999 and 2004. Chi-squared analyses and logistic regression models were used to examine the independent association of acculturation with CVD risk factors: hypertension, BMI, diabetes (HgbA1c ≥6.5), total cholesterol ≥ 240 mg/dl, HDL (male: &lt;40 mg/dl, female &lt;50 mg/dl). Models were adjusted for age, gender, insurance, education, income, having a usual place of care, and appropriate sampling weights. Nominal association between acculturation variables was assessed with the uncertainty coefficient (UC) (Range: -1 [100% negative association] to 1 [100% positive association]). Results: Of 8707 Hispanics, less acculturated adults, as measured through language, were slightly older (mean age 41 vs. 39), were more likely to have less than a high school education (66 vs. 25%), less likely to have a usual source of care (61 vs.79%), and more likely to be uninsured (57 vs. 27%). Only 8% were born in the US, 31% were US citizens, and 58% reported 15 yrs or less in the US. In fully adjusted models, the SAS and other language based acculturation measures showed null association with CVD risk while increasing years in the US was consistently associated with increasing risk over time of hypertension (ORs range: 1.1-2.3), obesity (ORs range: 1.2-2.4) and diabetes (ORs range: 1.0-2.6). Only obesity had similar point estimates and confidence intervals across acculturation measures (ORs range: 1.0 - 2.4). Moderate positive correlation was highest between language usually spoken at home and country of birth (UC=0.4) followed by US citizenship (UC=0.3). Conclusions: NHANES is widely used in the study of Hispanic health. Different acculturation measures demonstrate differing associations with CVD risk factors. In contrast to language-based measures, only length of residence in the US showed consist associations across CVD risk factors. Future research is needed to further characterize acculturation metrics among heterogeneous Hispanic populations.

Abstract P159: The Impact of Acculturation on Ideal Cardiovascular Health Metrics Among Hispanic Adults: Results from the National and Nutrition Examination Survey 1999-2010

Background: The American Heart Association has identified a set of 7 ideal health metrics that are associated with reduced cardiovascular disease mortality. Higher acculturation has been linked to increased risk of cardiovascular disease risk factors among Hispanics. We tested whether acculturation is associated with these ideal metrics in a large contemporary sample of Hispanic adults. Methods: We examined the association between acculturation and 7 ideal cardiovascular health metrics in the National Health and Nutrition Examination Survey (NHANES) from 1999-2010. Acculturation was measured by language use, with higher acculturation defined as the use of at least equal English and Spanish. The 7 ideal health metrics included not smoking, a body mass index (BMI) &lt;25 kg/m2, moderate intensity exercise (defined by weekly METs), a healthy diet (healthy diet score ≥2), and maintenance of normal values of cholesterol (&lt;200 mg/dL), fasting glucose (&lt;100 mg/dL), and blood pressure (&lt;120/&lt;80 mm Hg). Based on established guidelines, components were defined as poor, intermediate, or ideal. Chi-squared analyses and logistic regression models were used to examine the independent association between ideal health metrics and acculturation, adjusting for age, gender, insurance status, usual place of care and appropriate sampling weights. P values ≤ 0.05 were significant. Results: The study sample consisted of 8,707 Hispanic adults. As compared with more acculturated adults, less acculturated adults were slightly older (mean age 41.1 vs. 39.2, p=0.004), were more likely to have less than a high school education (67.1 vs. 25.1%, p&lt;0.001), less likely to have a usual source of care (61.3 vs. 79.1%, p&lt;0.001) and more likely to be uninsured (57.0 vs. 27.4%, p&lt;0.001). Less acculturated Hispanics were more likely to be nonsmokers (64.0 vs. 54.7%, p&lt;0.001) but were less likely to meet ideal health metrics for BMI, physical activity, cholesterol, and glycemic control as compared with more acculturated adults. There was no difference in the healthy diet score by acculturation. In a subset of participants with all 6 ideal health metrics (N=1516) excluding diet, lower acculturation was associated with a trend for higher odds of having 6 of the ideal health metrics in fully adjusted models (Odds Ratio 1.8 [95% CI 1.0-3.1]). Conclusion: Contrary to prior reports of the positive health effects of low acculturation, we found that lower acculturation is associated with poor cardiovascular health metrics in a national sample of Hispanic adults. However, this group is also heterogeneous and future studies should explore the complex role of acculturation in cardiovascular disease risk profiles.

Comparison of Experiences with Care Coordination for Children with Special Healthcare Needs (CSHCN) in Illinois

Background: Care coordination (CC), a central responsibility of the medical home, significantly impacts health outcomes of CSHCN. Most studies to date have focused on either provider provision of CC or patient experience with CC. Objective: We compared how providers for, and parents of, CSHCN experience subspecialty access, communication amongst physicians, and barriers to CC, and examined associated characteristics. Methods: Two datasets were analyzed: a survey of Illinois primary care pediatricians and the Illinois sample within the National Survey of CSHCN. Results: 376 physicians and 793 parents were analyzed. Providers and parents were highly satisfied with obtaining subspecialty referrals and with communication amongst doctors (76-92%), however 41% of parents and 38% of physicians identified CC barriers. Doctors more frequently reported CC barriers if employed by community hospitals (OR: 2.4 [95%CI: 1.2-4.6]), without academic appointments (OR: 1.6[1-2.4]), did not participate in a medical home project (OR: 4.5[1.7-12.1]), or cared for an overrepresentation of Hispanic patients (OR: 2.1[1.2-3.8]). Parents were 60% less likely to report poor doctor communication if they had a primary caregiver and 60% less likely to report difficulty with referrals if they had a usual place for care. Conclusions: Patients and physicians are overall highly satisfied with access to and communication with subspecialists, however over a third of parents and physicians of CSHCN, particularly non-academic community providers, report CC barriers.

Are There Differing Patterns of Health Care Access and Utilization Among Male Sexual Minorities in the United States?

Disparities in health care access and utilization among male sexual minorities in the United States were explored using data from the National Survey of Family Growth (N = 8,846). Bisexual men had a small disadvantage in health insurance coverage but no differences were found in health insurance or consistency of coverage between gay and heterosexual men. Gay men were more likely to have a usual place of care, but were not more likely to utilize services. The current study provides inconclusive evidence for systematic disparities in health care access and utilization among gay and bisexual men in the United States.

Factors Influencing Emergency Department Preference for Access to Healthcare

Introduction:African-Americans are more likely than Caucasians to access healthcare through the emergency department (ED); however, the reasons behind this pattern are unclear. The objective is to investigate the effect of race, insurance, socioeconomic status, and perceived health on the preference for ED use.Methods:This is a prospective study at a tertiary care ED from June to July 2009. Patients were surveyed to capture demographics, healthcare utilization, and baseline health status. The primary outcome of interest was patient-reported routine place of healthcare. Other outcomes included frequency of ED visits in the previous 6 months, barriers to primary care and patient perception of health using select questions from the Medical Outcomes Study Short Form 36 (SF-36).Results:Two hundred and ninety-two patients completed the survey of whom 58% were African-American and 44% were uninsured. African-Americans were equally likely to report 3 or more visits to the ED, but more likely to state a preference for the ED for their usual place of care (24% vs. 13%, p < 0.01). No significant differences between groups were found for barriers to primary care, including insurance. African-Americans less often reported comorbidities or hospitalization within the previous 6 months (23% vs. 34%, p = 0.04). On logistic regression modeling, African-Americans were more than 2 times as likely to select the ED as their usual place of healthcare (OR 2.24, 95% CI 1.22 – 4.08).Conclusion:African-Americans, independent of health insurance, are more likely than Caucasians to designate the ED as their routine place of healthcare.

Health care access and utilization among children of single working and nonworking mothers in the United States.

To examine indicators of health care access and utilization among children of working and nonworking single mothers in the United States, the authors used data on unmarried women participating in the 1997-2008 National Health Interview Survey who financially supported children under 18 years of age (n = 21,842). Stratified by maternal employment, the analyses assessed health care access and utilization for all children. Outcome variables included delayed care, unmet care, lack of prescription medication, no usual place of care, no well-child visit, and no doctor's visit. The analyses reveal that maternal employment status was not associated with health care access and utilization. The strongest predictors of low access/utilization included no health insurance and intermittent health insurance in the previous 12 months, relative to those with continuous private health insurance coverage (odds ratio ranges 3.2-13.5 and 1.3-10.3, respectively). Children with continuous public health insurance compared favorably with those having continuous private health insurance on three of six access/utilization indicators (odds ratio range 0.63-0.85). As these results show, health care access and utilization for the children of single mothers are not optimal. Passage of the U.S. Healthcare Reform Bill (HR 3590) will probably increase the number of children with health insurance and improve these indicators.

An Update on Assessing Development in the Pediatric Office: Has Anything Changed After Two Policy Statements?

Objective The aim of this study was to examine parental reports of receiving a child developmental assessment (DA), and the child, family, and type of health care setting characteristics and well-child care processes associated with receiving this aspect of preventive developmental care. Methods The 2007 National Survey of Children’s Health was used to study 16 223 children, aged 10 months to 4 years, who received a DA with a structured questionnaire from their primary care provider in the previous 12 months. Data were adjusted for child characteristics, family socioeconomic factors, type of health care setting, and processes of care. Results Few children were assessed for developmental delays by using developmental questionnaires (28%). A greater percentage of parents of children with public insurance reported receiving a developmental questionnaire compared with parents of children who were uninsured or privately insured (32% vs 26% and 25%, respectively; P = .02). The adjusted odds of receiving a developmental questionnaire were higher for children with public insurance than private insurance (odds ratio [OR] 1.35, 95% confidence interval [CI], 1.05–1.73), higher for children whose usual place of care was a clinic or health center than a doctor’s office (OR 1.36, 95% CI, 1.07–1.74), and higher for children reporting adequate family-centered care (OR 1.41, 95% CI, 1.14–1.74). Conclusions Parental receipt of developmental questionnaires is low and varies by type of insurance, type of place for usual source of care, and adequacy of family-centered care. There is room for improvement in the provision of developmental questionnaires and, our results suggest, areas for continuing research to understand variations in DA practices.

Self-Reported Use of Eye Care among Latinos: The Los Angeles Latino Eye Study

To identify the prevalence and determinants of self-reported eye care use in Latinos.Population-based ocular epidemiologic study in Latinos aged 40+ years living in La Puente, California.A total of 5455 participants.Univariate, multivariable, and stepwise logistic regression analyses were conducted to identify predisposing, enabling, and need variables associated with self-reported eye care use.Prevalence of self-reported use: eye care visit, having had a dilated examination in the past 12 months, ever having had a dilated examination, and odds ratios for factors associated with self-reported use.Overall, 36% of participants reported an eye care visit and 19% reported having a dilated examination in the past year. Fifty-seven percent reported ever having had a dilated eye examination. Greater eye care use was associated with older age, female gender, bilingual language proficiency (English and Spanish), more education, having health insurance, having a usual place for care, having a regular provider of care, a greater number of comorbidities, visual impairment, and lower vision-specific quality of life scores.Multiple modifiable factors are associated with greater use and access to eye care for Latinos. Modification of these factors should be a priority because visual impairment has significant impacts on well-being and mortality.

Reevaluating the Need for Concern Regarding Noncoverage Bias in Landline Surveys

We used recent data to reexamine whether the exclusion of adults from households with no telephone or only wireless phones may bias estimates derived from health-related telephone surveys. We calculated the difference between estimates for the full population of adults and estimates for adults with landline phones; data were from the 2007 National Health Interview Survey. When data from landline telephone surveys were weighted to match demographic characteristics of the full population, bias was generally less than 2 percentage points (range = 0.1-2.4). However, among young adults and low-income adults, we found greater bias (range = 1.7-5.9) for estimates of health insurance, smoking, binge drinking, influenza vaccination, and having a usual place for care. From 2004 to 2007, the potential for noncoverage bias increased. Bias can be reduced through weighting adjustments. Therefore, telephone surveys limited to landline households may still be appropriate for health surveys of all adults and for surveys of subpopulations regarding health status. However, for some behavioral risk factors and health care service use indicators, caution is warranted when using landline surveys to draw inferences about young or low-income adults.

The Effects of Barriers on Health Related Quality of Life (HRQL) and Compliance in Adult Asthmatics who are Followed in an Urban Community Health Care Facility

This cross sectional descriptive study sought to identify perceived barriers to follow-up care for adult asthmatics who are followed in two community health care facilities. A second purpose of the study was to determine the effect of any barriers to Health Related Quality of Life (HRQL) and compliance in the sample. Thirty-four adults completed a demographic and health status survey, the MiniAQLQ and the EWash Access to Health Care Survey. "Long waiting time in provider's office," "someone had to miss work," "cost of care too much, "and "long wait for an appointment" were the most prevalent perceived barriers in the sample. "Lack of transportation" was significantly associated with study participants who receive health care at one site or who stated the emergency room as their usual place of care. "Someone had to miss work" was significantly correlated with the following variables: employment, a higher annual household income, 1-2 daily medications for asthma, no overnight hospitalizations for asthma and no psychological co-morbidities. A higher reported HQOL was significantly correlated with study participants whose medical care needs were met and found access to local health care services. The only perceived barrier that was significantly correlated with compliance was study participants who "sometimes" had to reschedule an appointment with a health care provider due to "lack of transportation." The present study suggests that strategies designed to decrease the perceived barriers might improve compliance with the treatment regime, thus decreasing costs, absenteeism, and lack of continuity.

When a Usual Source of Care and Usual Provider Matter: Adult Prevention and Screening Services

To examine whether the usual source of preventive care, (having a usual place for care only or the combination of a usual place and provider compared with no usual source of preventive care) is associated with adults receiving recommended screening and prevention services. Using cross-sectional survey data for 24,138 adults (ages 18-64) from the 1999 National Health Interview Survey (NHIS), we estimated adjusted odds ratios using separate logistic regression models for receipt of five preventive services: influenza vaccine, Pap smear, mammogram, clinical breast exam, and prostate specific antigen. Having both a usual place and a usual provider was consistently associated with increased odds for receiving preventive care/screening services compared to having a place only or neither. Adults ages 50-64 with a usual place/provider had 2.8 times greater odds of receiving a past year flu shot compared with those who had neither. Men ages 50-64 with a usual place/provider had nearly 10 times higher odds of receiving a PSA test compared with men who had neither. Having a usual place/provider compared with having neither was associated with 3.9 times higher odds of clinical breast exam among women ages 20-64, 4.1 times higher odds of Pap testing among women ages 21-64, and 4.8 times higher odds of mammogram among women ages 40-64. Having both a usual place and usual provider is a key variable in determining whether adults receive recommended screening and prevention services and should be considered a fundamental component of any medical home model for adults.

Longitudinal Correlates of Health Care-Seeking Behaviors Among HIV-Seropositive Injection Drug Users

To identify modifiable factors associated with health care utilization by HIV-negative seropositive injection drug users (IDUs). We analyzed longitudinal data from 966 participants in a randomized controlled trial of a behavioral intervention designed to address medical care, adherence, and risk reduction. The outcomes of this study were usual place for care (clinic vs. emergency room) and frequency of primary care visits. Results of multiple logistic regression analysis showed that increase in "importance of HIV care scale" score (odds ratio [OR]=2.99; P<0.001), empowerment (OR=3.53; P<0.001), utilization of case management (OR=3.07; P=0.007), and having a stable residence (OR=2.63; P=0.008) were significantly associated with participants being "clinic users." Increase in importance of HIV care scale score (OR=5.65; P=0.01) increased empowerment (OR=2.42; P=0.005), taking greater control of one's health (OR=2.17; P=0.001), having health insurance (OR=2.58; P=0.003), utilization of case management (OR=3.14; P=0.027), and CD4 count>or=200 cells/mm (OR=2.09; P=0.007) were significantly associated with reporting 2 or more primary HIV care visits in the past 6 months. Future interventions for this population may be strengthened by addressing the importance of HIV primary care; empowering participants with respect to the health care system; and promoting linkages to case management, health insurance, and local housing programs.

Racial and Ethnic Disparities in the Prevalence and Management of Cardiovascular Risk Factors in the United States Workforce

To assess racial or ethnic differences in workers with respect to awareness, treatment, and control of hypertension, diabetes, and dyslipidemia, and to identify factors associated with these disparities. Analysis of nationally representative data collected from employed persons participating in the National Health and Nutrition Examination Survey 1999 to 2002, with sub-analyses by race and ethnicity. Mexican-American workers are less likely than non-Hispanic whites to be aware of their hypertension (odds ratio [OR] = 0.60; 95% confidence interval [CI] = 0.39-0.94) and less likely to be treated (OR = 0.45; 95% CI = 0.23-0.85); less likely to be aware (OR = 0.56; 95% CI = 0.33-0.93) and treated (OR = 0.33; 95% CI = 0.14-0.78) for dyslipidemia; and more likely to be aware of diabetes (OR = 3.01; 95% CI = 1.14-7.95). Non-Hispanic blacks treated for hypertension are less likely than whites to reach blood pressure goal (OR = 0.47; 95% CI = 0.33-0.66). Having a usual place of care is independently associated with awareness and treatment for hypertension, and treatment for dyslipidemia. Understanding cardiovascular health disparities in the workforce can help employers structure appropriate workplace screening and prevention programs.

Reduced Medication Access

Medication access is crucial to secondary stroke prevention. We assessed medication access and associated barriers to care across region and time in a national sample of US stroke survivors. Among all 5840 black or white stroke survivors aged > or =45 years responding to the National Health Interview Survey years 1997 to 2004, we examined inability to afford medications within the last 12 months across region (Northeast, Midwest, West, South) and time. With logistic regression, we adjusted associations between medication inaffordability and region and time for age, sex, race, neurological disability, comorbidity, health status, insurance, income and out-of-pocket medical expenses. In 2004, approximately 76,000 US stroke survivors were unable to afford medications. Lower medication affordability was reported among stroke survivors who were <65 years old, black, female, had high comorbidity or low health status. Compared with stroke survivors able to afford medications, those unable more frequently reported lack of transportation (15% versus 3%; P<0.001), no health insurance (16% versus 3%; P<0.001), no usual place of care (6% versus 2%; P=0.001), income <$20,000 (66% versus 40%; P<0.001) and out-of-pocket medical expenses > or =$2000 (35% versus 25%; P<0.001). From 1997 to 2004, inability to afford medications increased significantly from 8.1% to 12.7% (P(trend)=0.01) overall and increased in all US regions except the Northeast. We identified a vulnerable stroke survivor population with reduced medication access and increased barriers to medical care. Membership in this population has grown substantially from 1997 to 2004, potentially leading to increased recurrent stroke incidence.

Correlates of health care utilization among HIV-seropositive injection drug users

This study sought to identify correlates of poor health care utilization among HIV-positive injection drug users (IDUs) using Andersen's behavioural health model. We used baseline data from INSPIRE, a study of HIV-positive IDUs (n=1161) to identify predisposing, enabling, and need factors related to poor utilization (defined as fewer than two outpatient visits in the past six months, or identification of emergency room (ER) as the usual place for care). Using bivariate and multivariate models, we found a number of enabling factors that could facilitate the use of health care services such as having health insurance, having seen a case manager, and better engagement with health care providers. These enabling factors could be modified through interventions targeting HIV-positive IDUs. In addition, health insurance and case management appear to be important factors to address because they contributed in making other factors (e.g. lower education, lack of stable housing) non-significant barriers to outpatient care utilization. In the future, these findings may be used to inform the development of interventions that maximize use of scarce HIV resources and improve health care utilization among HIV-positive IDUs.