Stepping Stones From Childhood Adversity to Cardiovascular Disease and Premature Mortality.
Journal of the American Heart Association
Demographic and psychosocial factors associated with hair cortisol concentrations in preschool children.
Measuring socioeconomic adversity in early life
2019; 108 (7): 1267–77
Reinvesting in the doctor--patient relationship in the coming era of scarcity.
The American journal of bioethics : AJOB
; 6 (1): 33–34
Measuring socioeconomic adversity in early life.
Acta paediatrica (Oslo, Norway : 1992)
BACKGROUND: Early life stress has enduring effects on physical and mental health. Hair cortisol concentrations (HCCs) reflect exposures to contextual stressors in early life, but are understudied in preschool children.METHODS: Hair samples from children (N=693) during clinic visits (CVs) scheduled at 1-4 years (CV1-CV4) were measured using validated assay methods for HCC.RESULTS: HCCs were highest at CV1 and decreased at CV2-CV4, with no sex differences. Black children had higher HCC than White/other children; these differences persisted even after adjusting for socioeconomic factors. Bivariable analyses showed significant effects on HCC for Black race, with specific demographic and psychosocial factors at different ages. Multivariable analyses showed that higher HCC at CV1 were associated with Black race and male sex; at CV2 with Black race, lower maternal self-esteem, socioeconomic adversity, and the child's risk for developmental delay; at CV3 with Black race; at CV4 with maternal depression and the child's prior HCC values.CONCLUSIONS: HCCs were higher in Black children than White/other races; differences were related to maternal factors, socioeconomic adversity, and the child's risk for developmental delay. Public health measures to reduce disparities between Blacks and other races must also consider the long-term effects of chronic stress in early life.
View details for DOI 10.1038/s41390-019-0691-2
View details for PubMedID 31791042
When trauma hinders learning
PHI DELTA KAPPAN
2018; 99 (6): 39–44
Evaluating the Sustainability of School-Based Health Centers
PROGRESS IN COMMUNITY HEALTH PARTNERSHIPS-RESEARCH EDUCATION AND ACTION
2017; 11 (3): 225–32
AIM: Early life adversity in leads to enduring effects on physical and mental health, school performance, and other outcomes. We sought to identify potentially modifiable factors leading to socioeconomic adversity in early life.METHODS: We enrolled 1,503 pregnant women aged 16-40 years, without pregnancy complications or pre-existing conditions from Shelby County, Tennessee. Social, familial, and economic variables were analyzed using principal components (PCs) analyses to generate the Socioeconomic Adversity Index (SAI). This was replicated using the National Survey of Children's Health (NSCH). Health and social outcomes were compared across the quintile groups defined by SAI values at the county, state, and national levels.RESULTS: Significant differences occurred across the SAI Quintile-1 to Quintile-5 groups in marital status, household structure, annual income, education, and health insurance. Significantly worse health and social outcomes occurred in the lower vs. higher SAI quintiles, including maternal depression, parental incarceration, child's birthweight, and potential for child abuse. Maternal age and race also differed significantly across the SAI quintiles.CONCLUSION: Modifiable factors contributing to socioeconomic adversity in early life included marital status, household structure, annual income, education, and health insurance. Those exposed to greater socioeconomic adversity as defined by SAI values had significantly worse maternal and child outcomes. This article is protected by copyright. All rights reserved.
View details for PubMedID 30614554
Value in the Step 2 Clinical Skills Examination.
JAMA internal medicine
2017; 177 (2): 292-293
The Childhood Roots of Cardiovascular Disease Disparities.
Mayo Clinic proceedings
2017; 92 (9): 1415–21
The United States is facing a surge in the number of school-based health centers (SBHCs) owing to their success in delivering positive health outcomes and increasing access to care. To preserve this success, experts have developed frameworks for creating sustainable SBHCs; however, little research has affirmed or added to these models.This research seeks to analyze elements of sustainability in a case study of three SBHCs in San Diego, California, with the purpose of creating a research-based framework of SBHC sustainability to supplement expertly derived models.Using a mixed methods study design, data were collected from interviews with SBHC stakeholders, observations in SBHCs, and SBHC budgets. A grounded theory qualitative analysis and a quantitative budget analysis were completed to develop a theoretical framework for the sustainability of SBHCs.Forty-one interviews were conducted, 6 hours of observations were completed, and 3 years of SBHC budgets were analyzed to identify care coordination, community buy-in, community awareness, and SBHC partner cooperation as key themes of sustainability promoting patient retention for sustainable billing and reimbursement levels.These findings highlight the unique ways in which SBHCs gain community buy-in and awareness by becoming trusted sources of comprehensive and coordinated care within communities and among vulnerable populations. Findings also support ideas from expert models of SBHC sustainability calling for well-defined and executed community partnerships and quality coordinated care in the procurement of sustainable SBHC funding.
View details for DOI 10.1353/cpr.2017.0039
View details for Web of Science ID 000414458000002
View details for PubMedID 29056614
Gender Differences in Medicine-From Medical School to Medicare.
Mayo Clinic proceedings
2017; 92 (6): 855–57
Geography as Disparity: The Shifting Burden of Heart Disease.
2016; 133 (12): 1151–54
Parental Limited English Proficiency and Health Outcomes for Children With Special Health Care Needs: A Systematic Review
2014; 14 (2): 128-136
A recent national review of the social determinants of cardiovascular disease (CVD) underscored the growing recognition that poor socioeconomic conditions early in life place children at higher risk for CVD as adults. There is growing evidence that chronic elevation of allostatic load as a consequence of high levels of early childhood stress can trigger early atherosclerotic changes in children independently of behaviors. Elevated levels of circulating cortisol have been documented in children as young as 4 years who were raised in highly stressful circumstances. Chronic elevation of cortisol is associated with increased release of inflammatory proteins such as interleukin 6, which can lead to fibrosis and scarring in the vessel walls of the arterial circulation, resulting in increased intima-media thickness. Increased intima-media thickness of the carotid artery has been found in individuals with low socioeconomic status as early as age 18 years and has been associated with increased CVD risk throughout the adult years. The American Academy of Pediatrics has recommended that it is the task of pediatricians and other health care professionals to screen for toxic stress among children during their early years and to take steps known to reduce stress reactivity, thereby helping these children to reduce their risk of early atherosclerotic changes and increased CVD throughout the life course.
View details for PubMedID 28870356
Bending the Medicare Cost Curve for Physicians' Services: Lessons Learned from Canada
JOURNAL OF GENERAL INTERNAL MEDICINE
2012; 27 (11): 1555-1559
One in 10 US adults of childbearing age has limited English proficiency (LEP). Parental LEP is associated with worse health outcomes among healthy children. The relationship of parental LEP to health outcomes for children with special health care needs (CSHCN) has not been systematically reviewed.To conduct a systematic review of peer-reviewed literature examining relationships between parental LEP and health outcomes for CSHCN.PubMed, Scopus, Cochrane Library, Social Science Abstracts, bibliographies of included studies. Key search term categories: language, child, special health care needs, and health outcomes.US studies published between 1964 and 2012 were included if: 1) subjects were CSHCN; 2) studies included some measure of parental LEP; 3) at least 1 outcome measure of child health status, access, utilization, costs, or quality; and 4) primary or secondary data analysis.Three trained reviewers independently screened studies and extracted data. Two separate reviewers appraised studies for methodological rigor and quality.From 2765 titles and abstracts, 31 studies met eligibility criteria. Five studies assessed child health status, 12 assessed access, 8 assessed utilization, 2 assessed costs, and 14 assessed quality. Nearly all (29 of 31) studies used only parent- or child-reported outcome measures, rather than objective measures. LEP parents were substantially more likely than English-proficient parents to report that their CSHCN were uninsured and had no usual source of care or medical home. LEP parents were also less likely to report family-centered care and satisfaction with care. Disparities persisted for children with LEP parents after adjustment for ethnicity and socioeconomic status.Parental LEP is independently associated with worse health care access and quality for CSHCN. Health care providers should recognize LEP as an independent risk factor for poor health outcomes among CSHCN. Emerging models of chronic disease care should integrate and evaluate interventions that target access and quality disparities for LEP families.
View details for Web of Science ID 000333142500005
View details for PubMedID 24602575
Revolution or evolution? Putting the Flexner Report in context
2011; 45 (1): 17-22
Attrition From Premedical Studies Among Latinas: Case Studies
HISPANIC JOURNAL OF BEHAVIORAL SCIENCES
2010; 32 (4): 571-585
Mexican Immigrants in the US Living Far from the Border may Return to Mexico for Health Services
JOURNAL OF IMMIGRANT AND MINORITY HEALTH
2010; 12 (4): 610-614
In 1997 Congress created the Sustainable Growth Rate (SGR) formula for the payment of physicians under Part B of Medicare. SGR established a target rate of growth for aggregate costs of physician services under Part B, linked to growth in overall GDP. If growth in aggregate Part B costs exceeds the target, the rate at which physicians are paid in the following year is to be reduced by a corresponding amount. In SGR, Congress and the U.S. medical profession jointly confront a policy dilemma with no clear solution. For several years running, Congress has elected to postpone cuts in payment to physicians required under SGR. Absent further Congressional action, in 2013 physicians' fees under Part B of Medicare will be reduced by more than 30 %. The historical roots of SGR suggest that a potential solution lies in shifting to regional expenditure targets-an approach applied successfully in Canada in the 1970s when Canadian Medicare confronted rising physician fees. The commission that created what was to become SGR was aware of the lessons learned in Canada, and recommended that they also be applied to U.S. Medicare.
View details for DOI 10.1007/s11606-012-2091-8
View details for Web of Science ID 000310161500026
View details for PubMedID 22562407
View details for PubMedCentralID PMC3475834
Chemistry courses as the turning point for premedical students
ADVANCES IN HEALTH SCIENCES EDUCATION
2010; 15 (1): 45-54
This study explores to what extent and why Mexican immigrants in the U.S. living far from the border return to Mexico for medical services.Structured Spanish-language qualitative interviews were completed with a crosssectional sample of 10 Central Mexican immigrants living in Northern California and with 10 physicians and 25 former immigrants living in Central Mexico.Sixteen of the 35 current and former immigrants (46%) said they or a close friend or relative had returned to Mexico from the U.S. for health-related reasons. Participants returned to Mexico for care due to unsuccessful treatment in the U.S., the difficulty of accessing care in the U.S. and preference for Mexican care.Obtaining care in Mexico appears to be common. These findings have implications for the maintenance of continuity of care, for Mexico's healthcare system, and for the impact of changing border policies on immigrant health.
View details for DOI 10.1007/s10903-008-9213-8
View details for Web of Science ID 000281505900022
View details for PubMedID 19058007
The leaky pipeline: factors associated with early decline in interest in premedical studies among underrepresented minority undergraduate students.
2008; 83 (5): 503-511
Previous research has documented that negative experiences in chemistry courses are a major factor that discourages many students from continuing in premedical studies. This adverse impact affects women and students from under-represented minority (URM) groups disproportionately. To determine if chemistry courses have a similar effect at a large public university, we surveyed 1,036 students from three entering cohorts at the University of California, Berkeley. We surveyed students at the beginning of their first year at the university and again at the end of their second year. All subjects had indicated an interest in premedical studies at the time they entered the university. We conducted follow-up interviews with a stratified sub-set of 63 survey respondents to explore the factors that affected their level of interest in premedical studies. Using a 10-point scale, we found that the strength of interest in premedical studies declined for all racial/ethnic groups. In the follow-up interviews, students identified chemistry courses as the principal factor contributing to their reported loss of interest. URM students especially often stated that chemistry courses caused them to abandon their hopes of becoming a physician. Consistent with reports over more than 50 years, it appears that undergraduate courses in chemistry have the effect of discouraging otherwise qualified students, as reflected in their admission to one of the most highly selective public universities in the US, from continuing in premedical studies, especially in the case of URM students. Reassessment of this role for chemistry courses may be overdue.
View details for DOI 10.1007/s10459-009-9165-3
View details for Web of Science ID 000274107500004
View details for PubMedID 19504170
View details for PubMedCentralID PMC2814029
Planning services for the homeless in the San Francisco Peninsula
JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED
2007; 18 (4): 749-756
To determine the causes among underrepresented racial and ethnic minority groups (URM) of a decline in interest during the undergraduate years in pursuing a career in medicine.From fall 2002 through 2007, the authors conducted a longitudinal study of 362 incoming Stanford freshmen (23% URM) who indicated on a freshman survey that they hoped to become physicians. Using a 10-point scale of interest, the authors measured the change in students' levels of interest in continuing premedical studies between the beginning of freshman year and the end of sophomore year. Follow-up interviews were conducted with 68 participants, approximately half of whom had experienced decreases in interest in continuing as premeds, and half of whom who had experienced increases in interest.URM students showed a larger decline in interest than did non-URM students; women showed a larger decline than did men, independent of race or ethnicity. The authors found no association between scholastic ability as measured by SAT scores and changes in level of interest. The principal reason given by students for their loss of interest in continuing as premeds was a negative experience in one or more chemistry courses. Students also identified problems in the university's undergraduate advising system as a contributor.Largely because of negative experiences with chemistry classes, URM students and women show a disproportionate decline in interest in continuing in premedical studies, with the result that fewer apply to medical school.
View details for DOI 10.1097/ACM.0b013e31816bda16
View details for PubMedID 18448909
Ethics in public health research: a research protocol to evaluate the effectiveness of public-private partnerships as a means to improve health and welfare systems worldwide.
American journal of public health
2007; 97 (1): 19-25
A survey of clients seeking homeless services at agencies in the SF Peninsula, indicates that a disproportionate percentage are minority group members (African American and Hispanic) and veterans, and points to the need for integrated housing, social services, and health care for this vulnerable population.
View details for Web of Science ID 000252211100005
View details for PubMedID 17982204
Healthcare in the New Vietnam: Comparing patients' satisfaction with outpatient care in a traditional neighborhood clinic and a new, western-style clinic in Ho Chi Minh City
SOCIAL SCIENCE & MEDICINE
2006; 62 (5): 1229-1236
Public-private partnerships have become a common approach to health care problems worldwide. Many public-private partnerships were created during the late 1990s, but most were focused on specific diseases such as HIV/AIDS, tuberculosis, and malaria. Recently there has been enthusiasm for using public-private partnerships to improve the delivery of health and welfare services for a wider range of health problems, especially in developing countries. The success of public-private partnerships in this context appears to be mixed, and few data are available to evaluate their effectiveness. This analysis provides an overview of the history of health-related public-private partnerships during the past 20 years and describes a research protocol commissioned by the World Health Organization to evaluate the effectiveness of public-private partnerships in a research context.
View details for PubMedID 17138922
The practitioner's dilemma: Can we use a patient's race to predict genetics, ancestry, and the expected outcomes of treatment?
ANNALS OF INTERNAL MEDICINE
2005; 143 (11): 809-815
As Vietnam opens its economy to privatization, its system of healthcare will face a series of crucial tests. Vietnam's system of private healthcare--once comprised only of individual physicians holding clinic hours in their homes--has come to also include larger customer-oriented clinics based on an American business model. As the two models compete in the expanding private market, it becomes increasingly important to understand patients' perceptions of the alternative models of care. This study reports on interviews with 194 patients in two different types of private-sector clinics in Vietnam: a western-style clinic and a traditional style, after-hours clinic. In bivariate and multivariate analyses, we found that patients at the western style clinic reported both higher expectations of the facility and higher satisfaction with many aspects of care than patients at the after-hours clinic. These different perceptions appear to be based on the interpersonal manner of the physician seen and the clinic's delivery methods rather than perceptions of the physician's technical skill and method of treatment. These findings were unaffected by the ethnicity of physician seen. These findings suggest that patients in Vietnam recognize and prefer more customer-oriented care and amenities, regardless of physician ethnicity and perceive no significant differences in technical skill between the private delivery models.
View details for DOI 10.1016/j.socscimed.2005.07.015
View details for Web of Science ID 000236008800016
View details for PubMedID 16162387
Listening to patients: Cultural and linguistic barrier's to health care access
2005; 37 (3): 199-204
Recent research has identified genetic traits that can be used in a laboratory setting to distinguish among global population groups. In some genetic analyses, the population groups identified resemble groups that are historically categorized as "races." On the basis of these associations, some researchers have argued that a patient's race can be used to predict underlying genetic traits and from these traits, the expected outcomes of treatment. Others have questioned the use of race in this way, arguing that racially defined groups are so heterogeneous that predictions of individual characteristics derived from group averages are bound to be problematic. Practitioners today face the dilemma of translating this scientific debate into clinical decisions made 1 patient at a time. Is it or is it not appropriate to use a patient's self-identified "race" to help decide treatment? In contrast to the global population groups identified by genetic studies, the U.S. population has experienced substantial genetic admixture over time, weakening our ability to distinguish groups on the basis of meaningful genetic differences. Nonetheless, many researchers have suggested that these differences are still sufficient to identify racially specific uses for pharmaceutical and other treatments. A review of recent research on the treatment of hypertension and congestive heart failure finds that race-specific treatments of this type carry a substantial risk for treating patients--black or white--inappropriately, either by withholding a treatment that may be effective or by using a treatment that may be ineffective. Only by moving beyond historical concepts of "race" to examining a patient's individual socioeconomic, cultural, behavioral, and ancestral circumstances can a practitioner select the treatment that is most likely to be effective and in doing so, can best serve that patient's needs.
View details for Web of Science ID 000233884900005
View details for PubMedID 16330792
A time to listen.
Annals of internal medicine
2004; 140 (2): 144-?
Using a new method of gathering patient satisfaction data to assess the effects of organizational factors on primary care quality.
Joint Commission journal on quality improvement
2000; 26 (12): 713-723
Full access to medical care includes cultural and linguistic access as well as financial access. We sought to identify cultural and linguistic characteristics of low-income, ethnic minority patients' recent encounters with health care organizations that impede, and those that increase, health care access.We conducted four focus groups with ethnically homogeneous African American, Latino, Native American, and Pacific Islander patients. Study participants were "walked" through the stages of a medical encounter and asked to identify physician and staff behaviors that made the patient feel more comfortable (a surrogate for increasing access) and behaviors that made the patient feel less comfortable (a surrogate for decreasing access).African American and Native American patients in particular expressed overall satisfaction with their physicians' services. Patients from all groups saw nonphysician staff as frequently impeding access. Based on perceptions of negative stereotypes, Native American and Pacific Islander patients reported hostility toward physicians' efforts at prevention and patient education.For the ethnic minority patients in our study, most perceived that cultural impediments to access involved nonphysician staff. Closer collaborations between health care organizations and ethnic minority communities in the recruitment and training of staff may be needed to improve cultural and linguistic access to care.
View details for Web of Science ID 000227636000012
View details for PubMedID 15739136
The current state of health care in the former Soviet Union: Implications for health care policy and reform
AMERICAN JOURNAL OF PUBLIC HEALTH
1996; 86 (3): 307-312
As health care in the United States evolves increasingly toward managed care, there are continuing concerns about maintaining the quality of the physician-patient interaction, of which patient satisfaction is one measure. A quality assessment tool that measures both patient satisfaction with care and the ways organizational factors affect satisfaction will enable clinicians and administrators to redesign the care process accordingly. SURVEY METHODOLOGY: The measure of the quality of a physician office visit includes both the administration of a standardized satisfaction instrument and direct observation of the patient throughout the care process. This methodology was tested in 1997-1998 on an initial sample of 291 patients at a large multispecialty medical group in northern California. The surveyor recorded objective characteristics of the visit, surveyed patients about their impression of certain aspects of the visit related to satisfaction, and administered a standardized visit satisfaction survey. A second set of control patients who visited the same physician on the same day was contacted by phone and given the satisfaction survey two to four weeks later.Patients readily accepted the presence of a surveyor during their visit, with an overall response rate of 78%. While patients contacted retrospectively gave lower satisfaction ratings, the presence of a surveyor did not affect patients' satisfaction responses. Data obtained by using the concurrent methodology provides significant information about organizational factors influencing patient satisfaction.Measuring patient satisfaction concurrently during a physician office visit offers an attractive alternative to other methods of measuring this key aspect of quality.
View details for PubMedID 11143210
The ethics of Soviet medical practice: Behaviours and attitudes of physicians in Soviet Estonia
JOURNAL OF MEDICAL ETHICS
1996; 22 (1): 33-40
Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process.Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research.Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion.Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.
View details for Web of Science ID A1996UA07200006
View details for PubMedID 8604753
Medical education in the former Soviet Union
1996; 71 (2): 141-145
To study and report the attitudes and practices of physicians in a former Soviet republic regarding issues pertaining to patients' rights, physician negligence and the acceptance of gratuities from patients.Survey questionnaire administered to physicians in 1991 at the time of the Soviet breakup.Estonia, formerly a Soviet republic, now an independent state. SURVEY SAMPLE: A stratified, random sample of 1,000 physicians, representing approximately 20 per cent of practicing physicians under the age of 65.Most physicians shared information with patients about treatment risks and alternatives, with the exception of cancer patients: only a third of physicians tell the patient when cancer is suspected. Current practice at the time of the survey left patients few options when physician negligence occurred; most physicians feel that under a reformed system physician negligence should be handled within the local facility rather than by the government. It was common practice for physicians to receive gifts, tips, or preferential access to scarce consumer goods from their patients. Responses varied somewhat by facility and physician nationality.The ethics of Soviet medical practice were different in a number of ways from generally accepted norms in Western countries. Physicians' attitudes about the need for ethical reform suggest that there will be movement in Estonia towards a system of medical ethics that more closely approximates those in the West.
View details for Web of Science ID A1996TW45900010
View details for PubMedID 8932723
THE EFFECTS OF ORGANIZATIONAL-STRUCTURE ON PRIMARY-CARE OUTCOMES UNDER MANAGED CARE
ANNALS OF INTERNAL MEDICINE
1995; 122 (5): 353-359
After World War I, medical education in the Soviet Union and medical education in the United States headed in strikingly divergent directions. In keeping with the recommendations of the Flexner report, medical education in the United States became a university-based academic discipline based in the natural sciences. In contrast, the Soviet Union created a series of free-standing medical institutes whose admission, curricular, and pedagogic policies were centrally controlled in strict conformity with political doctrine. Notable features of the Soviet system were narrowly defined professional education; early specialization, beginning in the first year of medical school; and emphasis on empirical clinical training at the expense of scientifically based education. Despite the historical differences between Soviet and American medical education, there are several issues that face present-day medical educators in both the United States and the Soviet successor states. These include an overabundance of specialists, the need to provide equitable professional opportunities for physicians of both sexes, and the need to provide access to medical education for qualified candidates from underrepresented social or ethnic groups or from geographically remote regions.
View details for Web of Science ID A1996TU97400018
View details for PubMedID 8615926
The advent of managed care in the United States brings with it more and larger organizations involved in providing primary care. Studies of organizations in general suggest that large managed care organizations will have difficulty providing high-quality primary care largely because of their complexity and the fragmentation of their work force. Existing data confirm that these organizations have shortcomings in both patient and physician satisfaction. There are few data to indicate whether such organizations can mitigate these problems by saving costs through economies of scale. To offset their inherent weaknesses, large primary care organizations need to ensure patients' accessibility to their physicians, the continuity of the physician-patient relationship, a care environment conducive to a high-quality physician-patient interaction, and the clinical autonomy of physicians. Much additional research needs to be done to further understand these issues.
View details for Web of Science ID A1995QJ08500006
View details for PubMedID 7847647