Biomedical subjects

B Leake

Publications and source records attributed to B Leake.

At least 37 records · Page 2Linked to original sources

PubMed1997

Tuberculosis skin testing among homeless adults.

OBJECTIVE: To document the prevalence of tuberculosis (TB) skin test positivity among homeless adults in Los Angeles and determine whether certain characteristics of homelessness were risk factors for TB. DESIGN: Cross-sectional study. SETTING: Shelters, soup lines, and outdoor locations in the Skid Row and Westside areas of Los Angeles. PARTICIPANTS: A representative sample of 260 homeless adults. MEASUREMENTS AND MAIN RESULTS: Tuberculosis tine test reactivity was measured. The overall prevalence of TB skin test positivity was 32%:40% in the inner-city Skid Row area and 14% in the suburban Westside area. Using multiple logistic regression, TB skin test positivity was found to be associated with living in crowded or potentially crowded shelter conditions, long-term homelessness, geographic area, history of a psychiatric hospitalization, and age. CONCLUSIONS: Homeless adults living in congested inner-city areas are at high risk of both latent and active TB. Endemic risk factors and limited access to medical care support the need for aggressive treatment of active TB cases and innovative programs to ensure completion of prophylactic regimens by homeless individuals with latent infection.

Adult↗

PubMed1997

Under use of coronary angiography: application of a clinical method.

OBJECTIVE: To estimate the extent of under use of coronary angiography and to determine whether women, ethnic minorities and poor and uninsured patients are less likely than their counterparts to receive necessary coronary angiography. DESIGN: Retrospective cohort study employing chart review and patient interviews. SETTING: Four teaching hospitals: three government owned (public) and one private university medical center in Los Angeles, California. PATIENTS: Three hundred and fifty two patients who had a positive exercise stress test between 1 January 1990 and 30 June 1991 and met explicitly defined criteria for the necessity of coronary angiography established by a multidisciplinary expert panel. MAIN OUTCOME MEASURES: Percentage of patients who received necessary coronary angiography within 3 and 12 months following exercise stress testing, adjusted for demographic and clinical characteristics using logistic regression. RESULTS: Overall 43% received necessary coronary angiography within 3 months and 56% within 12 months of the stress test. Women were less likely than men to receive necessary coronary angiography. Adjusted odds ratio (AOR) 0.54, 95% confidence interval (CI) 0.34-0.90 for angiography within 3 months of the stress test; AOR 0.47, 95% CI 0.29-0.77 for angiography within 12 months of the stress test. Public hospital patients underwent necessary coronary angiography less often than private hospital patients. AOR 0.40, 95% CI 0.23-0.79 for within 3 months; AOR 0.52, 95% CI 0.30-0.91 for within 12 months. CONCLUSIONS: Under use of coronary angiography can be measured and occurs to a significant degree. It is important to develop standards of quality to address and safeguard against under use of necessary medical care.

Aged↗

PubMed1997

Reliability, validity, and composition of a subset of the Centers for Disease Control and Prevention acquired immunodeficiency syndrome knowledge questionnaire in a sample of homeless and impoverished adults.

OBJECTIVES: Measures of acquired immunodeficiency syndrome (AIDS)-related knowledge that have good psychometric properties are needed to evaluate the impact of educational interventions, particularly among impoverished populations. Few measures that satisfy these requirements are available. The authors describe the psychometric characteristics and composition of a subset of 21 AIDS knowledge items from the questionnaire used by the National Center for Health Statistics. METHODS: The study was conducted with a convenience sample of women and their significant others or close friends in nine homeless shelters and 11 residential drug recovery programs in the skid row area of Los Angeles from 1991 to 1993. Trained nurses and outreach workers collected data from 486 predominately African-American adults before delivery of well-established, culturally sensitive AIDS educational intervention. A subset of 334 participants were re-interviewed 6 months later. RESULTS: A total scale score was calculated from a one-factor solution, and two subscale scores were formed based on a two-factor solution. One subscale was composed of primarily cognitive items, whereas the second subscale contained mainly transmission-related items. The internal consistency reliability of the overall scale was 0.89; the two subscales had alphas of 0.80 and 0.92. The measures have face validity, and support for convergent validity was found. Further, even though AIDS knowledge in the sample was relatively high, all three measures showed marked improvement in the subsample of respondents who were re-interviewed after receiving AIDS-related educational information. CONCLUSIONS: These measures show promise for assessing AIDS knowledge and the efficacy of AIDS education programs in vulnerable populations. The findings reported here, however, are preliminary. Test-retest reliability needs to be examined, and additional studies are needed with samples that are more culturally diverse and include socially isolated individuals.

Acquired Immunodeficiency Syndrome↗

PubMed1996

The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium.

BACKGROUND: It is not certain whether older women with additional breast carcinoma risk factors are adequately screened or whether they are more likely to undergo screening than other older women. This study was conducted to determine whether selected risk factors influence the breast carcinoma screening rates of Medicare-insured older women (i.e., age 65 years or older). METHODS: Self-reported rates of screening mammography and clinical breast examination in the previous year were compared for women with benign breast disease, women with a family history of breast carcinoma, and women lacking these risks, using samples of non-Hispanic white, Medicare-insured women surveyed at the 5 National Cancer Institute Breast Cancer Screening Consortium sites in 1991 (n = 5376, mean age = 69.7 years) and 1994 (n = 5086, mean age = 69.7 years). RESULTS: In 1993, rates of screening mammography reported in the previous year at the 5 Consortium sites had a range of 46-61% for women with a family history of breast carcinoma, 49-66% for women with benign breast disease, and 31-43% for women lacking these risks. Women with a positive family history or a personal history of benign breast disease were also more likely to report having had a clinical breast examination in the previous year and having received a physician's mammography recommendation. A substantial proportion of older women with a positive family history remain inadequately screened, however. Between 25% and 35% of women in this group had not had a screening mammogram in the previous 2 years, while at some Consortium sites more than 20% reported never having had a mammogram in their lives. CONCLUSIONS: Older women with additional risk factors are more likely to undergo screening mammography. This is due partly to more frequent physician recommendations for screening and partly to more frequent provision of clinical breast examinations. However, a substantial proportion of high risk older women remain inadequately screened, despite widespread clinical consensus that these women should be regularly screened. Interventions that target older women with risk factors and their physicians appear warranted. Understanding the mechanisms by which risk factors influence screening is an important area for future research.

Aged↗

PubMed1996

Quality assurance in capitated physician groups. Where is the emphasis?

OBJECTIVE: To describe quality assurance (QA) programs implemented by capitated physician groups; to measure their relative emphasis on monitoring of overuse compared with underuse and monitoring and improving preventive services compared with chronic disease care; and to examine how group characteristics influence QA activity. DESIGN: Cross-sectional questionnaire. SETTING: A large network-model health maintenance organization in California (133 contracting physician groups). PARTICIPANTS: Ninety-four physician groups (71%) caring for 2.9 million capitated patients. MAIN OUTCOME MEASURES: Self-reported use of quality monitoring and improvement methods. RESULTS: All capitated physician groups conducted some QA. Groups' QA programs monitored areas subject to overuse, such as cesarean delivery and angioplasty rates, more than areas subject to underuse, such as childhood immunization rates and performance of retinal examinations for diabetic patients (64% vs 43%, P<.001). They monitored underuse of preventive services more than follow-up services for chronic diseases (54% vs 31%, P<.001). Groups also used reminders for preventive services more than they monitored follow-up services for chronic diseases (26% vs 15%, P<.01). Physician group characteristics independently associated with higher overall QA activity were greater number of years in existence, higher profitability, and capitated care penetration. CONCLUSION: Capitation places a large share of responsibility for QA in the hands of physician groups, but not all aspects of QA are being equally addressed. The emphasis on overuse may result from financial incentives inherent in capitation, while the focus on preventive services may stem from lack of adequate quality measurement tools for monitoring chronic disease care. Further research efforts should address how capitated physician groups might expand their QA programs to include monitoring of underuse, especially for patients with chronic disease.

California↗

PubMed1996

Organizing the community to target poor Latino children with asthma.

A community-university partnership to improve outcomes of care for poor Latino children (aged 6-14 years) with asthma in East Los Angeles was based on development of a community infrastructure. A family-centered educational program involved over 500 families. The Association of Latinos with Asthma and Allergy Symptoms (ALAAS) was formed. Parents report reductions in hospitalizations, emergency room, and acute care visits. Survival of the infrastructure following the end of grant funds is unlikely unless other resources offset the costs of volunteerism among poor families. Block grants to community agencies from established fund-raising groups might reduce dependency-producing practices currently employed to "help" the poor.

Adolescent↗

PubMed1996

Impoverished women at risk for AIDS. Social support variables.

1. Among impoverished and homeless individuals, little is known about the impact of social support, defined as emotional, informational, and tangible help that may have health-sustaining and stress-reducing functions. 2. A lack of positive social support, unemployment, and the prevalence of poor physical health and psychological distress may contribute to the extreme vulnerability of indigent populations. 3. Information is needed about the social support network of homeless and impoverished women related to personal and behavioral variables, particularly illegal drug use and risky sexual activity, and mental health status.

Acquired Immunodeficiency Syndrome↗

PubMed1996

Infrared tympanic temperature as a predictor of rectal temperature in warm and hot conditions.

BACKGROUND: Infrared (IR) thermometry has been proposed as a rapid, non-invasive means of monitoring core temperature. However, it has not been validated for use in warm to hot environments. HYPOTHESIS: IR tympanic temperature (Tty) accurately predicts rectal temperature (Tre) during simulated marching in warm and hot conditions. METHODS: Tty, and thermistor-derived Tre, aural canal (Tac) and cheek skin (T cheek) temperatures were monitored in seven males during 100 min of treadmill walking, in combat uniforms, at 5 km.h-1, slope 6%, in warm (30 degrees C, 60% RH) and hot (40 degrees C, 30% RH) conditions. RESULTS: Tty was significantly different to Tre in hot, but not warm, conditions. Final Tty was 0.2 degrees C < Tre in warm, but 0.4 degrees C > Tre in hot, conditions. From 60-100 min of the warm trial, Tty predicted Tre with a standard error of estimate (SEE) of 0.15 degrees C (r = 0.9, p < 0.0001). In a multiple regression model, the combination of Tty, Tac, and Tcheek reduced this SEE to 0.1 degrees C. In the H trial, from 60-100 min Tty predicted Tre with a SEE of 0.21 degrees C (r = 0.7, p < 0.0001). Tty and Tac correlated significantly in both trials. CONCLUSIONS: (1) the IR method should provide useful estimates of Tre in the field provided the influence of ambient conditions is taken into account; (2) the IR method is not as reliable as rectal monitoring in distinguishing accurately between degrees of heat strain; and (3) Tre prediction with the IR device may be improved in warm conditions if skin temperatures are combined with Tty.

Adult↗

PubMed1995

Effect of physician specialty on use of necessary coronary angiography.

OBJECTIVES: This study sought to determine whether having a cardiologist as a regular source of care influences likelihood of undergoing necessary coronary angiography. BACKGROUND: An important element of the current health policy debate is the respective roles of primary care and specialist physicians. However, there are few data on interspecialty differences in quality of care for patients with ischemic heart disease. METHODS: We contacted 243 patients by telephone (response rate 72%) who had positive (or very positive) exercise stress test results and met additional clinical criteria for necessary coronary angiography. Study patients were randomly sampled from those undergoing exercise stress testing at one university and three public hospitals in Los Angeles between January 1, 1990 and June 30, 1991. Patients were asked whether they had a regular source of care during the time after their exercise stress test and, if so, whether that provider was a cardiologist or cardiology clinic. RESULTS: Among survey responders, 47% underwent necessary coronary angiography within 3 months of exercise testing and 61% within 12 months. After adjustment for sociodemographics and clinical presentation, patients with a cardiologist as a regular source of care were more likely than all other patients to have undergone necessary angiography within 3 months (52% vs. 38%, p = 0.05) and within 12 months (74% vs. 44%, p = 0.0001) of the exercise test. At 3 months, there was a trend toward a more pronounced effect of ongoing cardiologic care within the public hospitals compared with the private hospital (p = 0.09 for interaction between hospital types). CONCLUSIONS: Patients with a cardiologist as a regular source of care were more likely than all other patients to undergo clinically necessary coronary angiography within both 3 and 12 months of exercise stress testing.

Cardiology↗

PubMed1995

Managed care and capitation in California: how do physicians at financial risk control their own utilization?

OBJECTIVE: To describe the structure and range of utilization management methods initiated by physicians in response to capitation. DESIGN: Cross-sectional questionnaire. SETTING: A large network-model health maintenance organization (133 contracting physician groups) in California. PARTICIPANTS: 94 (71%) physician groups caring for 2.9 million capitated patients. MEASUREMENTS: Self-reported use of five major utilization management methods. RESULTS: All physician groups reported using gate-keeping and preauthorization for certain referrals or tests. Most also used profiling of utilization patterns (79%), guidelines (70%), and managed care education (69%). Most physician groups asked gatekeepers to submit preauthorization requests for specialty referrals and restricted patient self-referral. For example, 60% of groups required preauthorization for an internal medicine subspecialty referral, and 7% allowed patient self-referral. Most groups also asked gatekeepers to obtain preauthorization for many tests (for example, 95% for magnetic resonance imaging and 53% for pulmonary function tests). Preauthorization requests were denied infrequently (less than 10% of the time) by more than 75% of groups. Of the 54 groups reporting utilization profiles to their physicians, 61% never adjusted for case-mix among patients and more than 60% suggested practice changes to their physicians based on utilization. Fewer than 35% of the groups used written guidelines for expensive tests that required preauthorization (such as angiography). CONCLUSIONS: Physicians are responding to capitation by using utilization management techniques, some at early stages of development, that were previously used only by insurers. This physician-initiated management approach represents a fundamental transformation in the practice of medicine.

California↗

PubMed1995

Quality-of-life outcomes in men treated for localized prostate cancer.

OBJECTIVE: To assess health-related quality of life (HRQOL) in men treated for clinically localized prostate cancer. DESIGN: A cross-sectional analysis of HRQOL after treatment with radical prostatectomy, pelvic irradiation, or observation alone for clinically localized prostatic adenocarcinoma, and in age-matched comparison patients. SETTING: A large managed care population in California. SUBJECTS: A total of 528 men, including 214 treated for clinically localized prostate cancer (41 with evidence of metastatic disease were excluded from this analysis) and 273 age-matched, ZIP code-matched comparison patients without prostate cancer. Cancer patients were analyzed in three treatment groups: radical prostatectomy (n = 98), primary pelvic irradiation (n = 56), and observation alone (n = 60). MAIN OUTCOME MEASURES: General HRQOL was measured with the RAND 36-Item Health Survey 1.0. Cancer-specific HRQOL was measured with the CAncer Rehabilitation Evaluation System-Short Form and the Functional Assessment of Cancer Therapy-General form. Disease-targeted quality of life was measured with a new instrument assessing function and bother in three organ systems: sexual, urinary, and bowel. RESULTS: No differences among treatment groups were seen in comparisons of general HRQOL: Significant differences among treatment groups were seen in both function and bother in the prostate-targeted measures of sexual, urinary, and bowel domains. When cancer patients were compared with men of similar age without prostate cancer, differences were seen in the sexual, urinary, and bowel function and bother but not in general HRQOL measures. Although cancer-free men were found not to have full potency or continence, prostate cancer patients treated with surgery or radiation reported significantly worse sexual, urinary, and bowel function than men without cancer. Men who had undergone nerve-sparing prostatectomy did not differ from those who had undergone standard prostatectomy, but the power to detect a difference was low. CONCLUSIONS: Although no differences were seen in general HRQOL, three disease-targeted domains were found to differ significantly among the treatment groups and comparison patients. Even after controlling for the sexual and urinary dysfunction experienced by older men without cancer, those receiving therapeutic interventions for their prostate cancer were found to have poorer disease-targeted HRQOL: We conclude that in addition to general HRQOL, disease-targeted measures must be used to assess outcomes of care in men treated for localized prostate cancer.

Adenocarcinoma↗

PubMed1995

Physician-reported determinants of screening mammography in older women: the impact of physician and practice characteristics.

OBJECTIVE: Despite having markedly higher breast cancer risk, compliance of older women with screening mammography has been poor. This study was undertaken to determine which physician and patient practice characteristics were associated with high self-reported mammography referral rates for older women. METHODS: Primary care physicians (n = 129) from three socioeconomically diverse communities in Los Angeles were surveyed. Agreement with annual screening and self-reported referral rates were assessed for two groups of women, those 65 to 74 years of age and those 75 years and older. Screening outcomes were compared with physician and patient practice characteristics using bivariate and multivariate techniques. RESULTS: Although 73% of physicians agreed with annual screening of women aged 65 to 74 years, only 24% of physicians reported actually screening most women seen in this age group. Similarly, 57% of physicians agreed that women age 75 years and older should be screened annually, but only 21% reported recommending mammograms for most women seen in this age group. In multivariate analysis, white physicians (adjusted OR = 9.1), younger physicians (adjusted OR = 3.85), and those who used the American Cancer Society's low cost mammography projects (adjusted OR = 5.01) were more likely to report screening the majority of women seen. DISCUSSION: This study suggests that although physicians' intentions to screen older women may be relatively high, a gap exists between intentions and what is reported to be accomplished in practice. Race/ethnicity and physician specialty were the two strongest predictors of high self-reported referral rates, suggesting that targeted interventions may be useful.

Age Factors↗

PubMed1995

Identifying modifiable risk factors for rehospitalization: a case-control study of seriously mentally ill persons in Mississippi.

OBJECTIVE: The authors sought to identify risk factors for rehospitalization in a seriously mentally ill population, focusing on factors that have the potential to be modified through community-based interventions. METHOD: A case-control design was used in which 101 "case" subjects (recently readmitted psychiatric patients) and a comparison group of 101 subjects living in the community who had been previously hospitalized at the same time as the case subjects, but who in contrast had not been readmitted, were matched on gender, ethnicity, and length of time at risk for rehospitalization. The setting was the Mississippi public mental health system during the first 3 months of 1988, including Mississippi State Hospital and the 10 community mental health regions in its catchment area. The subjects were between the ages of 18 and 55 years, had had at least one previous Mississippi State Hospital admission, and had a primary chart diagnosis of schizophrenia; 197 informants, mostly family members, were also included in the study. Data were collected from structured interviews of subjects and informants, direct observation ratings of subjects, Mississippi State Hospital administrative records, and community mental health center administrative records. RESULTS: Medication noncompliance, comorbid alcohol abuse, and a high level of criticism of subjects by informants were associated with greater risk of rehospitalization, while types and extent of outpatient service use, access to care, quality of life, and demographic variables (other than ethnicity and gender) were not. CONCLUSIONS: These findings imply that interventions aimed at improving medication compliance, reducing alcohol abuse, and helping families cope with their mentally ill relatives could reduce the risk of hospitalization in this population.

Adolescent↗

PubMed1995

Drugs, poverty, pregnancy, and foster care in Los Angeles, California, 1989 to 1991.

To determine the characteristics and childbearing histories of women whose infants entered foster care in Los Angeles County, we examined the cases of 1,155 drug-using women whose infants were removed from them at birth and 236 non-drug-using women whose infants were also removed at birth by court order (July 1989 through March 1991). All of the women were indigent, and less than half had graduated from high school. The drug-using women frequently had criminal records, and more than a quarter were homeless. Many comparison women had mental health problems, and some (16.7%) were teenagers under court custody. Overall, 80% of all the children born to both groups of women were under court jurisdiction. Data obtained after study infants' births on 926 drug-using women observed for 18 months revealed that 22% had borne another infant who was placed in foster care; half of these infants had a positive drug immunoassay. Of the 185 non-drug-using women with 18-month follow-ups, 7.6% had borne another child who was in foster care. The magnitude of the repeated childbearing recorded among both groups of women in this study shows that preventive programs including family planning, mental health services, and drug prevention or rehabilitation programs have not reached this population.

Adolescent↗

PubMed1994

The effect of risk on changes in breast cancer screening rates in Los Angeles, 1988-1990.

BACKGROUND: Although there have been clear secular trends of increased use of some breast cancer screening modalities, such as mammography, it is less certain that similar trends have occurred among high risk women. METHODS: Population-based surveys were conducted in three socioeconomically diverse Los Angeles communities in 1988 and 1990. Trends in breast cancer screening behavior and key determinants of screening were compared separately for women with a family history of breast cancer, a personal history of benign breast disease, and for women without these risks. RESULTS: In two independent samples drawn in 1988 and 1990, women at a higher risk of breast cancer (positive family history) showed smaller increases in the prevalence of self-reported breast cancer screening than a comparison group of women without a family history of breast cancer or a history of benign breast disease. This was especially true for family-history-positive minority women and women aged 65 years and older, for whom screening actually decreased. In 1990, mammograms for the prior year were reported by only 39% of women with a positive family history, 54% of women with benign breast disease, and 35% of women without these risks. Trends in physicians' office visit discussions of breast cancer screening paralleled trends observed in screening behavior. CONCLUSIONS: Although breast cancer screening increased substantially among lower risk women, rates were unchanged for women at increased risk because of a family history of breast cancer. By identifying and counseling higher risk women, physicians can play an important role in promoting appropriate screening to this group.

Adult↗

PubMed1994

The termination of a randomized clinical trial for poor Hispanic children.

OBJECTIVE: To conduct a randomized clinical trial of the Spanish version of an educational program designed to be an adjuvant to adequate medical care of children with asthma. DESIGN: Randomized, clinical trial. SETTING: Los Angeles County, Calif. PARTICIPANTS: One hundred thirty-eight Hispanic children, ages 7 to 12 years, from disadvantaged families. All had used emergency facilities of major local hospitals in the previous year. MEASUREMENT/MAIN RESULTS: As the study proceeded, it became apparent that subjects were receiving inadequate medical and nursing care and had numerous barriers to applying knowledge and self-care skills gained from the program. Realizing this, we considered it unethical to allow the control children to suffer for the duration of the trial (1 year). Therefore, all children received "adequate" care from the research staff, and the randomized clinical trial, as originally designed, was ended. The emergency department/hospital use by both groups was significantly reduced compared with previous experience. CONCLUSION: Those researchers conducting randomized trials involving poor children should be aware of the potential ethical problems inherent in such ventures.

Asthma↗

PubMed1994

Internal medicine patients' expectations for care during office visits.

OBJECTIVE: To describe internal medicine patients' expectations for care during office visits and to examine the relationship between fulfillment of expectations for care and visit satisfaction. DESIGN: Survey of patients and their physicians. SETTING: The internal medicine practice of faculty and housestaff at a large academic center in Southern California. PATIENTS: 396 patients aged 18 to 65 years were approached in the clinic waiting room prior to their scheduled visits; 337 (85%) agreed to participate and 304 (77%) turned in completed questionnaires. Postvisit physician surveys were received in 88% of the cases. MAIN MEASUREMENTS: The patients' previsit reports of the elements of care they thought necessary for their physicians to provide; the patients' and physicians' postvisit reports of the elements of care actually provided; and the patients' satisfaction with care. RESULTS: Among 28 specific elements of care, seven were considered necessary by a majority of the patients (examination of the eyes/ears/nose/throat, lungs, heart, and abdomen; blood testing; prognostic counseling; and discussion of patients' own ideas about management). A higher number of elements of care were thought necessary by patients who were nonwhite and had not completed college. Up to 38% of the patients reported not receiving elements of care they had considered necessary; specific agreement between physicians and patients about care not received ranged from 63% to 100%. Not receiving certain "necessary" elements of care was associated with lower visit satisfaction. CONCLUSION: Internal medicine patients at the center studied had specific expectations for the content of their physician visits. However, they routinely failed to receive some of the items they thought necessary. Unless patients' expectations are carefully elicited and dealt with the physician-patient relationship may be adversely affected.

Adolescent↗

PubMed1994

Personality hardiness, work-related stress, and health in hospital nurses.

Personality hardiness is a set of beliefs about oneself and the world one lives in. Hardier persons take control of their lives, believe that commitment to goals will result in positive outcomes, and perceive daily stressors as challenges. Hardiness has been linked with less stress and fewer health problems among various occupational groups. This study found that among 237 hospital nurses, work-related stress and emotional exhaustion were associated with greater health problems in the form of anxiety, depression, and somatic complaints. Hardier nurses reported less work-related stress, less emotional exhaustion, and less anxiety, depression, and somatization. This article discusses considerations for strengthening future studies concerned with the relationships between personality hardiness, work-related stress, and health in nurses.

Burnout, Professional↗