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ABSTRACT: Emergency department (ED) chest pain protocols often include an exercise stress test (EST) in an outpatient setting to further risk stratify patients initially identified as low risk for acute coronary syndrome. Our goal was to characterize the noncompliant patient population and delineate reasons for uncompleted EST.
We conducted retrospective chart review of all ED-scheduled ESTs over a 6-month period. Demographic and compliance information was abstracted using standardized instrument, a 1-month consecutive patient subset was identified, and a telephone interview was conducted with noncompliant patients to determine why they did not complete their EST.
From January to July 2007, 57% (378/668) of patients were noncompliant with the ED-scheduled EST. In the subset, 78% (78/100) did not complete the EST: 58 patients never showed for their scheduled EST and 20 patients showed but could not initiate the EST because it was deemed inappropriate by health care workers in the cardiovascular laboratory or they began the test and it was nondiagnostic. Noncompliant patients were more likely to be male, unmarried, African American, and uninsured compared to compliant patients (P < .05). The most commonly stated reasons for noncompliance were miscommunication, financial, or inconvenience of scheduled time. Employed patients were more likely to state financial reasons for noncompliance, whereas unemployed patients were more likely to state personal reasons (P < .05).
Our findings suggest lack of patient comprehension about purpose and logistics of EST completion. Based upon our data, the ED should confirm the appropriateness of the EST for each patient and improve patient communication and EST availability.
The American journal of emergency medicine 05/2011; 29(4):427-31. · 1.54 Impact Factor
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ABSTRACT: The objective of this study was to examine which factors are associated with increased cancer knowledge among a sample of 866 Arab Americans 40 years of age or older. Individuals were invited to attend a cancer educational intervention and obtain a free cancer health screening. They were asked to complete a precancer and postcancer knowledge survey after the brief educational intervention. Using logistic regression, we found that the intervention increased cancer knowledge and the variables most associated with this improvement were having low education, being unemployed, having lived in the USA for 0-5 years, older age, not having insurance, and not exercising. Our study showed that these interventions may be more effective if tailored to the participant's educational, employment, duration in the US, and health behavior status. Future studies should examine whether cancer screening actually increases after an educational intervention.
Journal of Cancer Education 03/2011; 26(1):139-46. · 0.76 Impact Factor
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ABSTRACT: The objectives of this study were to: (1) calculate age-specific and age-adjusted cause-specific mortality rates for Arab Americans; and (2) compare these rates with those for blacks and whites. Mortality rates were estimated using Michigan death certificate data, an Arab surname and first name list, and 2000 U.S. Census data. Age-specific rates, age-adjusted all-cause and cause-specific rates were calculated. Arab Americans (75+) had higher mortality rates than whites and blacks. Among men, all-cause and cause-specific mortality rates for Arab Americans were in the range of whites and blacks. However, Arab American men had lower mortality rates from cancer and chronic lower respiratory disease compared to both whites and blacks. Among women, Arab Americans had lower mortality rates from heart disease, cancer, stroke, and diabetes than whites and blacks. Arab Americans are growing in number. Future study should focus on designing rigorous separate analyses for this population.
Journal of Immigrant and Minority Health 02/2011; 14(2):236-41. · 1.16 Impact Factor
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ABSTRACT: Disparities exist in mammography use based on nativity status. Using the 2005 National Health Interview Survey, we examined the link between nativity status and mammography use in the past 2 years among women (≥40 years) and investigated whether acculturation was associated with mammography use among foreign-born women using multivariate analyses. Foreign-born women were less likely (OR = 0.75; 95% CI = 0.65, 0.87) to report mammography use compared to US born women. After adjusting for selected covariates, results were no longer statistically significant. Foreign-born women (≥65 years) who were not US citizens (i.e. less acculturated) were less likely (OR = 0.17; 95% CI = 0.06, 0.46) to report mammography use compared to naturalized citizens. Based on our findings, mammography use did not differ between US and foreign-born women. Therefore, the disparities in incidence and mortality rates observed between these groups may be due to other factors.
Journal of Immigrant and Minority Health 03/2010; 13(5):883-90. · 1.16 Impact Factor
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ABSTRACT: The objective of this review was to summarize the current literature of community-based colorectal cancer screening randomized controlled trials with multi-ethnic groups. The CDC reports 40% of adults do not receive time-appropriate colorectal cancer screening. Although overall screening rates have improved since 2000, disparities remain. Studies examining community characteristics may offer insight into improving screening rates and eliminating disparities. We identified community-based colorectal cancer screening studies using PubMed and Ovid Medline database searches. Inclusion criteria were: community-based, randomized controlled trials; English language; published from 1/2001 to 8/2009; all colorectal cancer screening test interventions recommended in the 2008 "Joint Consensus" report; and study participants from at least two racial/ethnic groups, with not more than 90% representation from one group. There were 29 relevant articles published during 2001-2009; with 15 meeting inclusion criteria. We categorized the final studies (n = 15) into the four categories of Patient mailings (n = 3), Telephone outreach (n = 3), Electronic/multimedia (n = 4), and Counseling/community education (n = 5). Of 15 studies, 11 (73%) demonstrated increased screening rates for the intervention group compared to controls, including all studies (100%) from the Patient mailings and Telephone outreach groups, 4 of 5 (80%) Counseling/community education studies, and 1 of 4 (25%) Electronic/multimedia interventions. Patient choice and tailoring of information were common features of trials that increased screening rates across study categories. Including community-level factors and social context may be useful in future design and evaluation of colorectal cancer interventions to reduce or prevent new cases of colorectal cancer.
Journal of Community Health 03/2010; 35(6):592-601. · 1.28 Impact Factor
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ABSTRACT: OBJECTIVE To compare achievement of the American Diabetes Association diabetes care recommendations for U.S.- and foreign-born individuals with diabetes. RESEARCH DESIGN AND METHODS Using the 2001-2006 Medical Expenditure Panel Surveys, we report estimates for receipt of a cholesterol test, routine checkup, influenza vaccination, eye examination, dental checkup, foot examination, and two or more A1C tests in 1 year for foreign- (n = 1,272) and U.S.-born (n = 5,811) individuals aged > or =18 years. We define a dichotomous variable representing full compliance with the above examinations. We provide descriptive characteristics of the sample and use multivariable analysis for each procedure with random effects logit regression. RESULTS Compared with U.S.-born individuals with diabetes, foreign-born individuals are younger, have lower education levels and income, are more likely to have public or no insurance, and are less likely to have a usual source of care. With adjustment for all potential confounders, foreign-born individuals are less likely to report having had an influenza vaccination (odds ratio 0.51 [95% CI 0.31-0.71]) or to be compliant with any one of the seven recommendations (0.64 [0.34-0.95]). CONCLUSIONS These findings demonstrate that immigrants are less likely than U.S.-born individuals with diabetes to adhere to any one of seven diabetes care recommendations in general and, specifically, are less likely to report having received an influenza vaccination. Because immigrants are less likely to use health care, clinicians should take advantage of the office visit to effectively communicate to the patient the importance of receiving an influenza vaccination.
Diabetes care 07/2009; 32(8):1459-63. · 8.09 Impact Factor
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ABSTRACT: Although the prevalence of disability for various racial and ethnic groups has been documented, little attention has been paid to Arab Americans in the United States.
We estimated the age- and sex-adjusted prevalence of disability among older Arab Americans and examined the association between nativity status and self-reported physical and self-care disability before and after controlling for covariates.
We used data from the 5% Public Use Microdata Samples of the 2000 US Census. Our sample included 4,225 individuals 65 years of age and older who identified with an Arab ancestry. Of these, 2,280 were foreign-born and 1,945 were US-born.
The age- and sex-adjusted prevalence of having a physical disability was 31.2% for foreign- and 23.4% for US-born older Arab Americans, and the age- and sex- adjusted prevalence of having a self-care disability was 13.5% for foreign- and 6.8% for US-born Arab Americans. Iraqis reported the highest estimates for both disabilities (physical, 36.2%; self-care, 19.8%) compared to other Arab ethnic groups. In the crude model, foreign-born Arab Americans were more likely (OR=1.32; 95% CI=1.28, 1.36) to report a physical disability compared to US-born Arab Americans. When adjusting for English language ability in the final model, the odds of having a physical disability for foreign-born Arab Americans was protective compared to US-born Arab Americans (OR=0.92; 95% CI=0.88, 0.96). In the crude model, foreign-born Arab Americans were 1.82 times (95% CI=1.74, 1.90) more likely to report a self-care disability compared to US-born Arab Americans. In the fully adjusted model, this association was slightly attenuated (OR=1.32; 95% CI=1.24, 1.41).
These findings indicate English language ability is associated with variations in reporting a physical disability. Future studies should include better measures of acculturation. Arab Americans are heterogeneous and should be disaggregated both by subgroups and from the white category in order to reveal a more accurate health and disease status profile for these groups. These efforts will assist in tailoring more effective interventions in reducing or preventing disability among Arab Americans 65 years of age and older.
Gerontology 09/2008; 55(2):153-61. · 2.78 Impact Factor
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ABSTRACT: To investigate the association between race and self-rated health among Hispanics and non-Hispanics using data from the National Health Interview Survey 2000-2003.
This analysis was limited to Hispanic and non-Hispanic whites and blacks > or =18 years of age. The outcome was self-rated health. The main independent variable was race/ethnicity, and potential confounders included sociodemographic characteristics, access to care, health behaviors, and comorbidities.
Non-Hispanic blacks exhibited the highest prevalence of fair/poor self-rated health compared to their white counterparts. In the adjusted analyses, compared to non-Hispanic whites, non-Hispanic blacks (OR: 1.21; 95% CI: 1.16-1.43), Hispanic whites (OR: 1.32; 95% CI: 1.14-1.52) and blacks (OR: 2.19; 95% CI: 1.07-4.49) were more likely to rate their health as fair/poor. There was no difference in self-rated health between Hispanic and non-Hispanic blacks.
This study underscores the importance of accounting for the racial heterogeneity among Hispanics when presenting health data. Ignoring race could mask health variations among Hispanics.
Journal of Immigrant and Minority Health 06/2008; 10(3):229-38. · 1.16 Impact Factor
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ABSTRACT: This article uses US Census data to investigate change over time in Arab American profiles. In 2000, a higher proportion of children (0 to 13 years of age), women, and those who lived in the Northeast identified with an Arab/non-Arab ancestry compared to an Arab-only ancestry. In 1980 and 2000, a higher proportion (~90%) of those who identified with an Arab/non-Arab ancestry was US born compared to only one-half of those who identified with an Arab-only ancestry. Those who identified with an Arab-only ancestry were more likely to not be US citizens than those who identified with an Arab/non-Arab ancestry. These findings suggest Arab Americans are a heterogeneous group.
International Migration Review 05/2008; 42(2):505 - 517. · 1.15 Impact Factor
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ABSTRACT: Although racial and ethnic differences in healthcare have been extensively documented in the United States, little attention has been paid to the quality of health care for the foreign-born population in the United States.
This study examines the association between patient perceptions of the patient-physician interaction and nativity status.
Cross-sectional telephone survey.
A total of 6674 individuals (US-born = 5156; foreign-born = 1518) 18 years of age and older.
Seven questions measuring the quality of patient-physician interactions.
Of the 7 outcome variables examined in the unadjusted logistic regression model, only 2 remained statistically significant in the fully adjusted model. For both the total sample and for Asians only, compared with US-born, foreign-born individuals were at greater odds [total sample, odds ratio (OR) = 1.43; 95% confidence interval (CI) = 1.01-2.04; Asians, OR = 3.25; 95% CI = 1.18-8.95] of reporting that their physician did not involve them in their care as much as they would have liked. Compared with US-born Asians, foreign-born Asians were at greater odds of reporting that their physician did not spend as much time with them as they would have liked (OR = 4.19; 95% CI = 1.68-10.46).
Findings from our study suggest that we should not only track disparities by race and ethnicity but also by nativity status.
Medical Care 03/2008; 46(2):185-91. · 3.41 Impact Factor
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ABSTRACT: We used data from the National Health Interview Survey (1997-2002) to examine the association between education and the prevalence of diabetes in US adults and whether this relation differs by race/ethnicity.
The analyses were limited to non-Hispanic Blacks, non-Hispanic Whites, and Hispanics. SUDAAN was used to account for the complex sampling design.
Educational attainment was inversely associated with the prevalence of diabetes. Individuals with less than a high-school diploma were 1.6 (95% confidence interval [CI]=1.4, 1.8) times more likely to have diabetes than those with at least a bachelor's degree. Whites and Hispanics exhibited a significant relation between diabetes and having less than a high-school education (odds ratio [OR]=1.7; 95% CI=1.5, 2.0; and OR=1.6; 95% CI=1.1, 2.3, respectively). In addition, the odds of having diabetes was stronger for women (OR=1.9; 95% CI=1.6, 2.4) than for men (OR=1.4; 95% CI=1.1, 1.6)
Educational attainment was inversely associated with diabetes prevalence among Whites, Hispanics, and women but not among Blacks. Education may have a different effect on diabetes health among different racial/ethnic groups.
American Journal of Public Health 10/2006; 96(9):1637-42. · 3.93 Impact Factor
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ABSTRACT: In this study, we examined the relative impact of self-management activities on glycaemic control in a population at high risk for developing complications.
Patients diagnosed with diabetes mellitus of at least 1 year in duration at 30 years of age or older were sampled from the Instituto de Mexico Seguro Social (IMSS) Family Medicine Clinics in Guadalajara, Mexico (n=800). Demographic, clinical and health behaviour variables were used to predict good/poor glycaemic control, as measured by haemoglobin Alc (A1C).
Most (72.24%) patients had poor control (A1C > or = 7.0). Hyperglycaemia was significantly associated with factors not under patient control, such as having diabetes for a longer time [odds ratio (OR) = 2.40, 95% confidence interval (CI) 1.39, 4.14], having a first-degree relative with diabetes (OR= 1.52; 95% CI 1.06, 2.19), and being prescribed anti-diabetic medications, e.g. insulin (OR = 7.88, 95% CI 2.42, 25.63). After controlling for these variables, the only self-management variable that reduced the likelihood of hyperglycaemia was following a special diet (OR=0.49; 95% CI 0.32, 0.76). Furthermore, depression had an important effect on self-management, as those with lower levels of depressive symptoms were more likely to follow a diet and exercise.
While patients in this population have little control over many factors associated with glycaemic control, an important exception is diet. However, because of the adverse effect of depression on dieting, both depression management and dietary education are important for this population.
Chronic Illness 06/2006; 2(2):77-85.
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ABSTRACT: The prevalence of diabetes and hypertension is increasing in the United States. Estimates for Blacks and Hispanics are higher compared to non-Hispanic Whites. When comparing estimates among racial and ethnic groups, Whites are used as the reference category. Whites are a very heterogeneous group, comprising persons having origins in Europe, North America, or the Middle East. The objective of this paper was to examine the association between nativity and self-reported diabetes and hypertension among a sample of non-Hispanic Whites including individuals born in the Middle East (referred to as Arab Americans; n=425) and born in the United States (n=79,228).
We use data from the 2000-2003 National Health Interview Surveys (NHIS). The NHIS is an annual, face-to-face interview of the civilian, noninstitutionalized US population that uses a three-stage stratified cluster probability sampling design.
Logistic regression was used to estimate odds ratios and 95% confidence intervals for the association between nativity and self-reported diabetes and hypertension among non-Hispanic Whites.
We found that the prevalence of diabetes was 4.8% for Arab Americans and 6.9% for non-Hispanic Whites (not significant). Similarly, the prevalence of hypertension was 13.4% for Arab Americans and 24.5% for non-Hispanic Whites (P<.0001). No association between country of birth, diabetes, or hypertension was seen.
Nativity status was not significantly associated with self-reported diabetes and hypertension among non-Hispanic Whites. Future studies should examine ethnic heterogeneity among non-Hispanic Whites.
Ethnicity & disease 02/2006; 16(3):699-705. · 0.90 Impact Factor
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ABSTRACT: Screening guidelines proposed by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus have been endorsed by several medical societies. However, one-third of cases are undiagnosed, and complications at the time of diagnosis indicate that disease may have been present for several years before diagnosis. This study evaluates the effectiveness of the guidelines for detecting new cases of diabetes mellitus. By using a cross-sectional, representative sample of the United States (National Health and Nutritional Examination Survey, NHANES III), the guidelines are tested on adults, 20 years and older without a prior diagnosis of diabetes. Individuals are classified as nondiabetics (n = 6,241) or as having undiagnosed diabetes (n = 274) based on their blood glucose. Screening when one risk factor is present, as stated in the guidelines, has a true-positive rate of 100% and would require that 83% of the population be tested. Screening when two risk factors are present is more efficient, with a comparable true-positive rate (98%), but requires that only 59% of the population be tested. A notable finding is the earlier age of onset among minorities, which may be associated with other health disparities. Because diabetes occurs at younger ages in minorities, screening whites who are > or =40 and minorities > or =30 years of age has a high true-positive rate (95%) and also reduces testing (60%). The screening guidelines would be effective, if followed, and would essentially eliminate undiagnosed cases of diabetes.
Proceedings of the National Academy of Sciences 09/2003; 100(18):10574-9. · 9.68 Impact Factor
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The Journal of the American Board of Family Medicine 21(3):249-50. · 2.05 Impact Factor
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ABSTRACT: We investigated the association between a cumulative biological risk or allostatic score and all-cause mortality risk. We used 13,715 records of participants aged 25 years and older from the Third National Health and Nutrition Examination Survey (NHANES III) linked to the National Death Index.
We specified all-cause mortality using the underlying cause of death in the death certificate. We calculated time to death from interview date through December 31, 2000, as person-years of follow-up using the NHANES III interview month and year. We used Cox proportional hazards regression to estimate hazard ratios (HRs) relating all-cause mortality risk for those with an allostatic score of 2 and > or = 3 relative to those with an allostatic score of < or = 1.
After controlling for age, gender, race/ethnicity, education, and income, mortality rates were 40% (HR = 1.40, 95% confidence interval [CI] 1.11, 1.76) and 88% (HR = 1.88, 95% CI 1.56, 2.26) higher for participants with an allostatic score of 2 and > or = 3, respectively, compared with those with a score of < or = 1. The death rate associated with allostatic score for each racial/ethnic group differed with age.
The allostatic score increased the risk of all-cause mortality. Moreover, this increased risk was observed for adults younger than 65 years of age regardless of their race/ethnicity. Thus, allostatic score may be a contributor to premature death in the U.S.
Public Health Reports 125(6):810-6. · 1.27 Impact Factor
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ABSTRACT: To provide an overview of the Community Health Fellowship Program (CHFP), describe the types of projects completed by the community health fellows from 2005 to 2009 and to assess the program's effectiveness from the perspective of fellows and community partners.
We developed the CHFP for training medical students in community-based participatory research (CBPR), and understanding the components of successful community partnerships for addressing health disparities in underserved communities. The program has didactic and applied community research components.
From 2005 to 2009, fellows completed 25 research projects with 19 different community partners. Fellows reported favorable attitudes about the program, their mentors, and their community projects; their research knowledge increased significantly in most areas, especially their ability to develop a succinct research question, familiarity with CBPR, and delivering a formal research presentation (Wilcoxon signed-rank test, P <.05). Community partners reported favorable attitudes toward the fellows and the program; using a 5-point Likert scale (1 = not favorable, 5 = very favorable), they reported highly favorable attitudes about fellows' level of responsibility (4.85), level of cooperation (4.85), familiarity with the needs of the medically underserved (4.69), and knowledge of how to apply local solutions to health problems (4.54).
The CHFP has high favorability and support among fellows and community partners; the program can serve as a prototype for training future physicians in understanding and addressing the needs of the underserved, through community partnerships, and community-based participatory research.
Journal of public health management and practice: JPHMP 17(4):363-8. · 0.96 Impact Factor
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ABSTRACT: We estimated the prevalence of self-reported diabetes in Hispanic subgroup (Puerto Rican, Mexican, Mexican American, Cuban, Dominican, Central and South American, and other Hispanic), non-Hispanic black, and non-Hispanic white populations aged 20 years and older.
Using the National Health Interview Survey 1997-2005, we limited these analyses to 272,041 records of adults aged 20 years and older, including 46,749 records for Hispanic respondents. We used logistic regression to assess the strength of the association between race/ethnicity and self-reported diabetes before and after adjusting for selected characteristics.
Compared with non-Hispanic white respondents, Mexican American (odds ratio [OR] = 2.02; 95% confidence interval [CI] 1.75, 2.34), Mexican (OR=1.52; 95% CI 1.31, 1.91), Puerto Rican (OR=1.53; 95% CI 1.23, 1.91), other Hispanic (OR=2.08; 95% CI 1.68, 2.58), and non-Hispanic black (OR=1.47; 95% CI 1.35, 1.61) respondents had greater odds of reporting diabetes. When compared with non-Hispanic white respondents, Mexican American respondents with less than a high school diploma had the lowest odds of reporting diabetes, while those with at least a college degree had greater odds of reporting diabetes. However, Puerto Rican respondents with less than a high school education, Mexican respondents with at least some college education, and other Hispanic respondents with at least a high school diploma/general equivalency diploma had greater odds of reporting diabetes.
Although Hispanic respondents bear a greater burden of diabetes than non-Hispanic white respondents, this burden is unevenly distributed across subgroups. These findings call attention to data disaggregation whenever possible for U.S. racial/ethnic populations classified under categories considered homogeneous.
Public Health Reports 124(5):702-10. · 1.27 Impact Factor
